Are you prepared for the long-term effects of COVID-19 on your health plan?

Most health plans saw an overall reduction in cost in 2020 despite significant increases related to respiratory conditions caused by COVID-19. While this reduction may appear to point toward a healthier workforce (due to decreased contact with germs and illness) on the surface, digging a bit deeper reveals that many simply put off or avoided vital treatment and care.

Because of COVID-19 concerns, an estimated 41% of U.S. adults delayed or avoided medical care including urgent or emergency care and routine care.*

The deferment of care may not be initially life-threatening, but could lead to serious health implications, pain, and greatly increase future plan costs.

What does this mean for the employees on your health plan?

• Existing chronic conditions will become worse without regular treatment and the probability of related complications increases.
• The emergence of new chronic conditions can be missed and go undiagnosed and untreated.
• Routine screenings for things like breast and colon cancer are missed, resulting in delayed detection.
• Existing behavioral health treatments are interrupted, and a greater segment of the population is at risk for such disorders.

All of these add up to greater future costs for your health plan. While this may all seem overwhelming, there are ways to prepare for this increased cost and mitigate the effects on your health plan.

1. Increase access to virtual care
   One of the biggest things your organization can do to help your employees and lower plan costs is to increase access to virtual care for both acute and chronic patients. Our new normal requires multiple avenues for patients to receive care. Also, robust access to virtual care eliminates the largest cause of care deferment during the pandemic.
2. Encourage employees to use their healthcare and stop delaying routine care any longer
   It is important that your organization encourages employees to utilize their health plans to receive all of the care they may have deferred over the past year. While this may result in a spike in claims in the short term, the long-term benefits of a healthy workforce far exceed the immediate costs. While increased utilization may seem counter-productive to controlling health plan costs, it is routine care that helps keep employees healthy and protects plans from experiencing large, unexpected claims.

*Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1250–1257. DOI: http://dx.doi.org/10.15585/mmwr.mm6936a4

Can short-term disability be used for mental health conditions?

The everyday stressors of life during the COVID-19 pandemic left many school employees dealing with new or exasperated mental health concerns. While every organization approaches mental health benefits differently, we have received questions about an employee’s ability to use short-term disability benefits to help with mental health issues.

Check out the information below to expertly navigate short-term disability benefits as they relate to mental health conditions.

Do mental health conditions qualify an employee for short-term disability?

The answer is — it depends! First and foremost, the determination that any illness qualifies an employee for short-term disability is based on three things:

1. Your organization’s short-term disability requirements
2. How the health plan administrator or carrier interprets the plan requirements
3. A professional diagnosis of the illness

Oftentimes, carriers lean heavily on a professional diagnosis and treatment plan when evaluating whether a condition qualifies for short-term disability. The disability carrier will take into account:

• the severity of the illness, and
• whether or not it wholly and continuously disables an employee to the point that they can no longer engage in their regular work.

Does my organization have any say in whether an illness qualifies for short-term disability?

If your organization’s short-term disability benefits are fully insured (administered by a carrier), the carrier will determine whether an illness qualifies based on the criteria listed above.

If your organization’s short-term disability benefits are self-insured, your organization can decide whether an illness qualifies using the criteria above.

NOTE: Determinations should be made on a universal and reasonable basis. It is also important that all determinations, as well as the determination process, be adequately documented.

How should we handle short-term disability requests that are submitted due to mental illness?

We recommend following four simple steps to help your organization handle short-term disability requests for any type of illness:

1. Clearly and adequately communicate plan requirements with employees. Make sure plan certifications are distributed to ALL employees to help create a baseline understanding of what the plan provides.
2. File claims early and include all required documentation for appropriate healthcare professionals. This helps the process move as quickly and smoothly as possible.
3. Take ALL mental health claims seriously. Maintain a sensitive and professional approach when assisting employees who are looking for any type of mental health support.
4. Take advantage of your resources! If employees are requesting more mental health support, reach out to all partners, such as your SET SEG account executive, Employee Assistance Program (EAP), and insurance agent.