Consumerism

1
Consumerism and Actuarial Science in A 21st
Century Intelligent Health System
Ronald E. Bachman FSA. MAAA President
CEO Healthcare Visions, Inc. 404-697-7376
ronbachman_at_healthcarevisions.net www.healthcarevi
sions.net   Sr. Fellow - Center for Health
Transformation Sr. Fellow - Georgia Public
Policy Foundation Fellow - Wye River Group on
Health
Healthcare Visions, Inc. Creating the
Possible
2
What Is a 21st Century Intelligent Health System?

• In a 21st Century Intelligent Health System, the
  individual has
• Accurate, timely knowledge of personal health
  needs,
• Access to the best information about how to
  maintain personal health,
• Knowledge of whom to see and where to go for
  health services,
• And confidence that health providers are
  practicing medicine using best practices based on
  the most up-to-date understanding of
  outcomes-based medicine.
• In a 21st Century Intelligent Health System, the
  individual has the right to know the price and
  quality information about health services in the
  most accurate, least expensive, and most
  convenient manner possible.
• In a 21st Century Intelligent Health System, the
  individual is the center of knowledge and
  decision-making and has responsibility for his or
  her own health.

3
Consumer-directed or Consumerism?

• Consumer-directed health plans (CDHPs) utilizing
  an HRA or HSA are the newest weapon in the
  arsenal to reduce healthcare cost.
• But will this approach really lower your cost?

• CDHPs are a good start and can developing
  experience shows they can lower costs.
• CDHPs are a good 1st generation attempt. The
  market is moving rapidly to 2nd generation and
  beyond.
• The transformation is NOT to CDHP but to
  Consumerism.
• Actuaries must go beyond traditional models to
  reflect the behavioral change component of a
  consumerism design.

4
Healthcare Consumerism

• Healthcare Consumerism is about transforming a
  health benefit plan into one that puts economic
  purchasing powerand decision-makingin the hands
  of participants.
• Its about supplying the information and decision
  support tools they need, along with financial
  incentives, rewards, and other benefits that
  encourage personal involvement in altering health
  and healthcare purchasing behaviors.

5
Elements of Healthcare Consumerism

• 1. Budgeting monthly versus annual
• 2. Risk Sharing pooled claims for large groups
• 3. Savings NEW with advent of HRAs and HSAs

6
The Core of Consumerism

• The Unifying Theme
• for a
• Health and Healthcare Strategy is

Behavioral Change
Implement only if it supports behavioral change
consistent with the strategy
7
Two Basic Principles for Successful Consumerism

• Must work for the Sickest Members, as well as the
  healthy
• 2. Must work for those not wanting to get
  involved in decision-making, as well as the
  techies

8
Mega Trends

1. Personal Responsibility
2. Self-Help, Self-Care
3. Individual Ownership
4. Portability
5. Transparency (the Right to Know)
6. Consumerism (Empowerment)

9
The Evolution of Healthcare and
ConsumerismFuture Generations of Consumer
Directed Healthcare

2nd Generation CDHC Focus on Behavior Changes
Traditional Plans with ConsumerInformation
1st Generation CDHC Focus on
Discretionary Spending
4th Generation CDHC Personalized
Health Healthcare
3rd Generation CDHC Integrated Health
Performance
Traditional Plans
Behavioral Change and Cost Management
Potential Low Impact ---- ---- ---- ---- ----
---- ---- ---- ---- High Impact
10
Major Building Blocks of Consumerism

Personal Accounts
It is the creative development, efficient
delivery, efficacy, and successful integration of
these elements that will prove the success or
failure of consumerism.
Wellness/Prevention Early Intervention
Disease Management
Information Decision Support
Incentives Rewards
11
2nd Generation CDHC Focus on Behavior Changes

1st Generation CDHC Focus on
Discretionary Spending
4th Generation CDHC Personalized
Health Healthcare
Summary A peek into the future of Consumerism
3rd Generation CDHC Integrated Health
Performance
Personal Accounts
Initial Account Only Activity Compliance Rewards Indiv. Group Corporate Metric Rewards Specialized Accts, Matching HRAs, Expanded QME
100 Basic Preventive Care Web-based behavior change support programs Worksite wellness, safety, stress error reduction Genomics, predictive modeling push technology
Information, health coach Compliance Awards, disease specific allowances Population Mgmt, IHM, Integrated Back-to-Work Wireless cyber support, cultural DM, Holistic care
Passive Info Discretionary Expenses Personal health mgmt, info with incentives to access Health performance info, integrated health work data Arrive in time info and services, information therapy
Cash, tickets, Trinkets Zero balance acct, activity based incentives Non-health corporate metric driven incentives Personal development plan incentives, health status related
Wellness/Prevention Early Intervention
Disease Management
Information Decision Support
Incentives Rewards
12
Using Information Incentives To Change
Behaviors
Low Users Low Users Medium Users High Users High Users Very High Users
No Claims Generally Healthy Acute Episodic Conditions O/P, Low In/P, High Maternity Acute Episodic Conditions O/P, Low In/P, High Maternity Acute Episodic Conditions O/P, Low In/P, High Maternity Chronic Persistent . Conditions . O/P, Low In/P, High Chronic Persistent . Conditions . O/P, Low In/P, High Catastrophic
Mem 15 48 14 3 3 12 4 1
Dollars 0 12 15 12 5 21 20 15

Mem 63 63 32 32 32 17 17 17
Dollars 12 12 32 32 32 56 56 56
Prevention
Wellness - Lifestyle
Wellness - Lifestyle
Minimize
Minimize
Maximize
Maximize
Wellness - Clinical
Early Intervention
Wellness - Clinical
13
Personal Health ManagementDecision Support
Information
Low Users Low Users Medium Users Medium Users Medium Users High Users High Users Very High Users
No Claims Generally Healthy Acute Episodic Conditions Acute Episodic Conditions Acute Episodic Conditions Chronic Persistent Conditions Chronic Persistent Conditions Catastrophic
No Claims Generally Healthy O/P, Low In/P, High Maternity O/P, Low In/P, High Catastrophic
Ee
Dollars
Ee
Dollars
Pre-Natal Care
Reduce Variation in Evidence-Based Medicine
Reduce Variation in Evidence-Based Medicine
Patient Safety Centers of Excellence Patient Ad
vocacy/ Case Management
DiseaseManagement
Discretionary Expenses
Psycho-Social Factors / Integrated Absence
Management
14
Care Continuum and Tools for Changing Behaviors
Acute Conditionse.g., Infections, Respiratory,
Lacerations
Health Promotion
Health Risk Management
Chronic Disease Management
High Cost Case Management
Website
Patient Identification and enrollment
Health Risk Assessment
Navigational Support
Address Comorbid Conditions
Targeted Behavior Modification
HealthyLifestyle Promotion
Patient Advocacy
Practice Guidelines
Physical Activity Campaign
Care Coordination
Care Coordination
Address Comorbid Conditions
Integrated Services, Communications, Measurement
and Evaluation
15
Integrated Health Management ProgramAn
Implementation Option for Multiple Generations
General Manager
Personal Care Accts. FSAs, HRAs, HSAs
The secret is cooperation and synergy between
components supporting the corporate strategies
Integrated Absence Mgmt
Acute Case Mgmt
Disease Mgmt Programs
Demand Management
Prevention
Wellness
Communication
Education
Utilization and Case Management
NETWORK A / TPA A
NETWORK B / TPA B
16
Potential Savings from Full Implementation of
ConsumerismAchievement of savings and improved
outcomes is dependent upon both the Type and
Effectiveness of the programs implemented.
  Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)   Gross Savings as of Total Plan Costs (Programs Applicable to All Members)
 
Effective Programs Implemented Traditional plans Traditional plans Traditional plans  
Effective Programs Implemented Consumerism Plans Consumerism Plans Consumerism Plans
Effective Programs Implemented Passive Passive 1st Generation 2nd Generation 3rd Gen Future
Basic Basic 2 3 7 10
Expanded Expanded 3-4 5-8 12-15.0 20.0
Complete Complete 4 7 17 25
Comprehensive (Future) Comprehensive (Future) 5 10 20 30
Excludes Carry-over HRAs/HSAs and any added
Administrative Costs of Specialized Programs
17
Major Actuarial Issues

• Anti-selection,
• Value of wellness,
• Disease management ROI,
• Actuarial credits for behavioral change

18
Understanding Risk Selection and
Anti-selection The primary drivers of risk
selection are employee cost and the relative
benefit richness of the competing
options. Employees will tend to choose the
option expected to provide the best economic
benefit for their situation. For healthy
individuals the selection is usually low cost/low
benefit options. For less healthy individuals the
selection is usually high cost/high benefit
options.

Selection effect is at least directionally
predictable in most cases. Mitigating factors
tend to reduce the magnitude of selection.
Health care costs are not fully predictable.
Plan choices are usually made at a family unit
level versus the individual level. .
19
Potential Anti-Selection from CDHC on an
Optional Basis

• Introduction of CDHC on an optional basis will
  limit the cost reduction because fewer members
  will be impacted and because the members that do
  select CDHC are likely to have an existing
  favorable health status (anti-selection).
  Adopting companies and its members can benefit
  most by introducing consumerism with both a CDHC
  option and consumerism for all other plans.

Example - Selection in An Option Environment Example - Selection in An Option Environment Example - Selection in An Option Environment Example - Selection in An Option Environment
OPTION 1 Current Plan OPTION 1 Current Plan OPTION 2 - CDHC OPTION 2 - CDHC
Members Participating Clms/Part.Mbr. Vs Clms/All Mbrs. Remaining Members Clms/Part.Mbr. Vs Clms/All Mbrs.
90 101 10 87
70 103 30 92
50 103 50 97
20
Consumerism Choices involve Options for
Behavioral Change rather than Optional Plan
Designs

• Consumerism Choices
• Wellness
• Preventive care
• Early Intervention
• Lifestyle Options (diet, exercise, smoking,
  safety)
• Self-help, self care
• Discretionary Expenses (e.g. OV, ER, Rx)
• Value purchasing (e.g. DXL, o/p vs. in/p)
• Participation in Disease Management Programs
• Compliance with Evidence Based Medicine
  Treatment Plans

21
Survey ResultsWellness Assessment Risk Factors
22
Value of Wellness What is it?

• How Much Physical Activity Do the Experts
  Recommend? 30? 60? 90? Minutes of What?
• The Centers for Disease Control and Prevention
  and the American College of Sports Medicine
  recommend the following
• 20 minutes of vigorous-intensity physical
  activity 3 times a week or
• 30 minutes of moderate-intensity physical
  activity 5 or more times a week.
• What is moderate-intensity physical activity? Any
  activity that burns 3.5 to 7 calories per minute
  (e.g., walking briskly).
• What is vigorous-intensity physical activity?
  Any activity that burns 7 or more calories per
  minute (e.g.,
• climbing up and down stairs).

23
National Business Group on HealthComments on
Wellness

• Recent studies indicate that moderate increases
  in employees physical activity levels can result
  in significant decreases in company costs.
  Although existing research is limited, employers
  may use calculation tools and internal data to
  calculate the potential savings of an effective
  physical activity promotion program.
• To reach a rough estimate of the cost of its
  employees physical inactivity, a company could
  turn to www.activelivingleadership.org for a new
  online tool.
• This Physical Inactivity Cost Calculator was
  developed by, among others, the Active Living
  Leadership Initiative, Fifty Plus Lifelong
  Fitness and the National Coalition for Promoting
  Physical Activity and Health.

24
Examples of Corporate Wellness ROI

• Motorolas wellness programs which saves the
  company
• 3.93 for every 1 invested.
• Northeast Utilities WellAware Program which in
  its first 24 months reduced lifestyle and
  behavioral claims by 1,400,000.
• Caterpillars Healthy Balance program which is
  projected to result in long term savings of 700
  million by 2015.
• Johnson Johnsons Health and Wellness Program
  which has produced average annual health care
  savings of 224.66 per employee.

25
Wellness ROI Studies

• Many studies have focused specifically on the
  return on investment (ROI) from worksite health
  promotion and disease prevention programs.
• Findings on the return on investment for health
  promotion and disease management programs were
  reported for nine employers Canada North
  America Life Chevron. City of Mesa, AZ General
  Mills General Motors Johnson Johnson Pacific
  Bell Procter Gamble and Tenneco. These
  programs provide health education to their
  employees to promote behaviors that will improve
  health or prevent disease, and typically include
  exercise programs, health-risk appraisal, weight
  control, nutrition information, stress
  management, disease screening, and smoking
  cessation.
• The review found significant return on investment
  for the programs provided by these nine
  employers, with the range of benefit-to-cost
  ratios, ranging from 1.49 to 4.91 in benefits
  per dollar spent on the program, and a median of
  3.14.

26
Savings from National Wellness Program

• Savings estimates revealed that participation in
  the National Wellness Program was associated with
  significant savings in dollars per employee from
  1991 to 1995, with the highest dollar savings
  achieved in 1995 (16 per employee per month).
• Evaluation of the program showed that health risk
  assessment was associated with significant and
  substantial reductions in healthcare costs.
• Employees who completed one, two, or three health
  risk assessments on average had lower 1997 health
  care costs of 112.89, 134.22, and 152.29,
  respectively. Employees who had completed at
  least one health risk assessment and participated
  in an additional wellness activity had an average
  cost savings of 200.35 per year.

27
CIGNA Wellness Savings

• The Working Well Moms Program has decreased
  pharmacy costs 62 fewer prescriptions for
  breast-fed children. The program has also
  contributed to decreased medical costs a
  savings of 240,000 in healthcare expenses. In
  addition, program participants have 74 fewer
  absences per 100 mothers, a savings of 60,000 in
  lost time annually.
• The Working Well Triumph Program has resulted in
  healthcare costs savings of more than 900 per
  program participant.
• The Working Well Flu Shots Program participants
  have 29 less
• absenteeism as compared to employees not
  getting a shot. This produced a savings of 33
  per employee participant. The overall return on
  investment for the program was 3 to 1.
• CIGNAs smoking cessation program helped 67
  percent of its participants quit smoking after 12
  months, a quit rate up to three times higher than
  comparable smoking cessation programs. CIGNA
  estimates saving 949 in health care costs for
  each successful participant, a return on
  investment of 9.5 to 1.

28
Disease Management for Chronic and Persistent
Conditions

• The Agriculture and Health and Human Services
  Departments Dietary Guidelines for Americans
  2005 recommend the following
• To reduce the risk of chronic diseaseat least
  30 minutes of moderate-intensity physical
  activity on most, preferably all days of the
  week
• To prevent the gradual accumulation of excess
  weight in adulthood, up to 30 additional minutes
  per day may be required over the 30 minutes for
  reduction of chronic disease risk and other
  health benefits and
• To sustain weight loss for previously
  overweight/obese people, about 60 to 90 minutes
  of moderate-intensity physical activity per day
  is recommended.

29
Disease Management Program ROI
30
First Year Aetna HealthFund Members2004 results
(9 mos.) show low medical cost increase
Continuously Enrolled Members Allowed claims
Medical Claims Change
2003 Study (13.5K members) 3.7 increase in medical cost
2004 Study (9 mos.) (49K members) Early indicators 6 increase in medical cost over 2003
Change in Utilization ( of Units) 2003 Study (12 months of data) 2004 Study (9 months of data)
Inpatient Admissions -5.2 -6.7
ER Visits -2.6 -15.9
Outpatient Events -14.4 -4.6
ALL Office Visits -3.3 -3.4
PCP Visits -10.9 -12.3
Specialists visits 3.4 3.6
Note 12 month continuously enrolled results due
in August
31
What Happens in the Second Year to Allowed
Claims?
260






1Q 03 2Q 03 3Q 03 4Q 03 1Q 04 2Q 04 3Q 04 4Q 04
10.3
PPO
240
220
AHF
Allowed Claims PMPM
200
180
8.7
160
140

• Utilization in AHF increased at a lower rate
  than PPO, based on allowed claims
• Reinforces assumption that AHF trend will be 1
  below PPO
• Studies will continue to evaluate AHF trend
  into the third year

Allowed Claims are total claims, eligible for
payment before benefit plan is applied Based
on all AHF members from 18 of 19 plan sponsors in
2003 study one plan sponsor removed due to large
increase in AHF enrollment.
32
Highlights of the 2003 Aetna HealthFund 12-Month
Study

• Lower medical cost increase, applicable to
  first-year AHF members - 3.7 compared to double
  digit PPO plans
• Diabetics continue to seek necessary care,
  relative to comparative populations
• Increases in certain preventive care services
• Reduction in pharmacy scripts and increased
  generic usage
• Increased use of online tools, information, and
  satisfied members

33
2004 United Health Plan Experience

• The iPlan study found
• A drop in the number of claims per 1,000
  enrollees compared to the year before enrollment
  
• A decrease in total emergency room visits,
  illustrating more selective, responsible use of
  emergency services
• Significantly less-than-expected medical cost
  trends (per member/per month) than for
  traditional health plans when iPlan was the only
  option, the annual cost trend was less than 1
  percent
• Reductions in specialist visits, outpatient
  surgeries and radiology and lab services and
• Higher utilization of preventive services among
  iPlan participants.

34
LumenosKey Results Utilization Impact

• 15 reduction in pharmacy costs
• 92 generic substitution rate (open formulary,
  100 of rebates go back to employer)
• 5 increase in preventive care expenditures
• 18 reduction in outpatient visits
• 85 graduation rate (Health Coach Program)
• 42 HRA completion with incentive 28 opt-in to
  Health Coach
• 60 of clients offer integrated health
  improvement incentives.

35

• Are HSAs the right vehicle for large employer
  groups?

Yes, If.. Or No, Because. Need to
Understand the Consumer Movement the
Transformation that is Underway
36
HSAs and HRAs Very Different

• HSA A law, with specific requirements and
  benefit design requirements.
• Most TAX ADVANTAGED vehicle ever created
• 
  
• HRAs No Law, this is a regulatory creation
  based upon an IRS ruling.
• Most FLEXIBLE vehicle ever created

37
Incentive Awards - Three Very Different Personal
Care Accounts

• FSAs Traditional Group Plans
• Health Reimbursements Arrangements (HRAs)
  Employers choice for cash flow flexible
  incentive based medical plan benefit designs
  (best suited for self-insured groups)
• Health Savings Accounts (HSAs) Employees
  choice for funded portable triple tax advantaged
  with High Deductible Health Plans (best suited
  for individuals and small groups)
• Combination Accounts creative but confusing

38
Important Differences between Use of HRAs and
HSAs for Supporting Behavioral Change
Generation 1 Initial Account Only Generation 2 Activity Compliance Rewards Generation 3 Indiv. Group Corporate Metric Rewards Generation 4 Specialized Accts, Matching HRAs, Expanded QME
Personal Care Accounts
Health Reimbursement Arrangements
1. Any Amount 2. Notional Acct 3. Employer Determined 4. Employer Only Contributions 1. Flexible Activity Compliance Rewards 2. Employer Determined 3. Can not be cashed out 4. Must be used for healthcare 1. Flexible Indiv Group Rewards 2. Employer Determined 3. Can not be cashed out 4. Must be used for healthcare 1. Specialized Notional Accts, 2. Can terminate by employer rules 3. Potential IRS Expanded QME
Health Savings Accounts
1. Amounts Set by law 2. Real Dollars in Acct 3. Er or Ee Contrib 4. Contributions up to plan deductible of 1000-2650 Single 2000-5250 Family 1. Ltd Potential 2. Must give Cash Option 3. Awards must be same amt or same of deductible 3. HSA can be used (with 10 penalty) for non- healthcare expenses 1. Ltd Potential 2. All participants must receive same amount or same of deductible 3. Difficult to use for Group Incentives 1. Ltd Potential 2. 100 Vested Portable 3. Can use matching HRAs, 4. Potential IRS Expanded QME
39
The Evolution of Personal Care Accounts

Current State
Combination Accounts
FSAs
HRAs
HSAs
Employer-based Healthcare Traditional (Use it or
Lose it) Special Purpose Non-Plan
Employer-based healthcare Special Purpose
Accounts Incentive Matching
Employer-based Healthcare with Individual
Accountability
Individual-based Healthcare Employer-based Define
d Contribution Developments
40
Are HSAs the Wave of the Future?Which Point of
View Direction will We Take?

• Yes, if.
• 1. we recognize the HSA legislation and
  regulations as a good start and another building
  block for consumerism and behavioral change.
• 2. there is additional legislation/regulation to
  support large Er interests in providing HSAs (use
  for healthcare only, Rx coverage problem,
  combination accounts).
• 3. there is legislative support for the common
  use of FSAs for targeted needs, HSAs as Health
  Savings Accounts and HRAs as Health
  Reimbursement Arrangements.
• No, because.
• 1. they were not legislated/regulated with large
  employers in mind.
• 2. of a desire to promote individual insurance
  over individual ownership (under employer and
  individual policies)
• 3. they are just a tool to cost shift to
  employees, they can not reward behavior change
• 4. they are only desirable to the young, healthy,
  and wealthy

41

• Are HSAs the right vehicle for large employer
  groups?

Yes, If.. Or No, Because. Need to
Understand the Consumer Movement the
Transformation that is Underway
42
The Fundamental Policy Question

• Will Legislation/Regulation Use HSAs to
• mainly promote portable Individual Small
  Group Insurance,
• OR
• expand Personal Care Account ownership through
  in both an employer-based and individual-based
  healthcare system thru HSAs, HRAs, and FSAs.

43
Growth of Personal Care Accounts

• HRAs HSAs
• 2000 None None
• 2001 19,000 None
• 2002 53,000 None
• 2003 394,000 None
• 2004(est) 1-1.5M 400,000
• 2005(est) 3.2 M 1.0M
• 2006(est) 6.0M ???
• 2007(est) 12-15M ???
• Deliotte Consulting

44
The Answer Flexible Health Savings Accounts
(FHSAs)

• FHSAs would have the tax advantages of HSAs and
  the key flexibilities of HRAs.
• Basic Principles
• 1. Retain personal responsibility goal of
  HSA/HDHPs
• 2. Focus on Behavior Change
• 3. Recognize value of Pay for Compliance as a
  driver for behavior change and shared savings
  with personal responsibility
• 4. Expand adoption and funding of HSAs by large
  employers

45
Flexible Health Savings Accounts (FHSAs)The Next
Generation

• Four needs that would allow FHSAs the flexibility
  to
• 1. Provide financial Rewards and Incentives for
  Behavioral Change.
• 2. Encourage Employer/Carrier FHSA contributions
  towards healthcare
• 3. Be provided with plan designs other than HDHPs
• 4. Address FHSA/HSA Technical Issues

46
FHSA Flexibilty to Provide Financial Rewards and
Incentives for Behavioral Change

• 1.  Allow for compliance incentives under disease
  management programs (e.g. diabetes, asthma, CHF)
  and wellness initiatives (e.g. wellness
  assessments, smoking cessation, etc.).
• 2. Change Comparability Rule to mean all members
  under a given program of care or treatment, such
  as, a disease management or wellness program.
• 3. Rewards and/or incentives should not be
  limited by the deductible limit, but should be
  consistent with expected savings from programs
  for which participation is being rewarded.

47
FHSA Flexibility to Encourage Employer
Contributions to Healthcare

• Allow employers/carriers to voluntarily contract
  with employees to require employer/carrier funded
  FHSAs to be used only for healthcare expenses
  while employed and covered under the plan.
• 2. Remove cap on employer/carrier funded FHSA
  contributions or expand to at least the plans
  Maximum Out-Of-Pocket total exposure in a given
  calendar year. 

48
FHSAs Flexibility to be Provided with Plan
Designs Other than HDHPs

• 1. Preventive drugs include maintenance drugs.
  Drugs now defined as preventive by the Treasury
  Dept. can be covered below the deductible, while
  the cost of maintenance drugs is now included in
  the deductible.
• 2. Allow Rx to exist as carve out benefits at
  least for prescription drugs associated with
  chronic and persistent disease states
• 3. Allow incentive only based FHSAs for
  employer/carrier only funding under non-HDHPs
  (i.e. no initial FHSA funding or employee
  funding)
• 4. Allow some mental health and substance abuse
  benefits (besides EAPs) to be included under
  preventive care.

49
FHSA Flexibility - Technical Issues

• 1. Allow FHSA/HSAs to go into effect on the first
  day of coverage is effective.
• 2. Allow FHSA/HSA contributions for a full
  calendar year regardless of when a plan is
  effective.
• 3. Allow FHSA/HSAs to be used to pay for health
  coverage premiums (other than current limited use
  for (1) Premiums for coverage under the
  Consolidated Omnibus Budget Reconciliation Act
  (COBRA), and (2) premiums for HDHP coverage for
  those who receive federal or state unemployment
  compensation).
• 4. Allow Flexibility to "post-date" the FHSA/HSA
  effective date so that FHSA/HSA dollars can cover
  expenses incurred before the account was
  established. Allow the account to be opened under
  a "provisional status" until the necessary
  paperwork is filed, at which time the account
  becomes active.

50
The Ultimate Successful Implementation of
Consumerism

• Its about moving from a
• benefit
• to an
• accumulating asset.