Safe and Simple FixedCost SelfFunded Medical Coverage Plus Refund - - PowerPoint PPT Presentation

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Safe and Simple FixedCost SelfFunded Medical Coverage Plus Refund - - PowerPoint PPT Presentation

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Safe and Simple FixedCost SelfFunded Medical Coverage Plus Refund Assisters Overview June 15, 2017 June 15, 2017 Subject to Change Without Notice 1 Disclaimer But first a word from our lawyers: This presentation summarizes

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Safe and Simple Fixed‐Cost Self‐Funded Medical Coverage Plus Refund Assisters Overview

June 15, 2017

June 15, 2017 Subject to Change Without Notice 1

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Disclaimer

But first a word from our lawyers: This presentation summarizes information concerning the benefits, networks, underwriting and other elements of the Protect Plans. It is not a controlling document and does not supersede the most current versions of The Protect Plan Underwriting Guide, Summary of Benefits and Coverage, Summary Plan Description and the stop-loss policies. All information in this presentation is subject to change without notice. In other words, we’ve tried to be accurate. If it’s wrong we apologize, but it’s not binding.

June 15, 2017 Subject to Change Without Notice 2

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What Employers Want

Something different … and better An advantage Something like fixed‐cost, self‐funded plans

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Two Solutions

Insurgency Benefits offers two safe and simple, fixed‐cost self‐funded medical coverage programs

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Self-Funded Made Simple

Self‐Funded can be complicated … … but it doesn’t have to be

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Why Consider Self-Funding

Claims lower than expected = refund Claims higher than expected = stop‐loss Heads clients win. Tails they don’t lose

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It’s that simple

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Agenda

  • 1. Self‐Funded Basics and Key Terms
  • 2. Plans and Underwriting Overview
  • 3. Resources
  • 4. The Team
  • 5. Questions and Answers

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SELF‐FUNDING BASICS AND KEY TERMS

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Self-Funded Basics: Part I

Traditional Insurance:

  • State regulation
  • Insurer pays claims – keeps surplus

Self‐Funded Programs:

  • Federal regulation
  • Employer pays claims – keeps surplus

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8 Key Terms

Claims Fund … 1 Claims Surplus … 2 Stop‐Loss or Excess‐Loss Coverage … 3

  • Specific Stop‐Loss … 4
  • Aggregate Stop‐Loss … 5

Attachment Point … 6 Contract Period … 7 Run‐Out … 8 Terminal Liability Option (TLO) … 9

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Key Terms

Claims Fund: money set aside by employers to pay claims Claims Surplus: money remaining in the claims fund after the contract period

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Key Terms

Stop‐Loss or Excess Loss Coverage: shields plan sponsors (employers) from excessive claims

  • Specific: caps claims on any one individual
  • Aggregate: caps overall claims

Attachment Point: the claim amount at which stop‐loss coverage kicks‐in

  • Deductible for stop‐loss coverage

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Key Terms

Contract Period: time period during which eligible claims must be incurred and paid for to be covered by excess loss carrier

  • Expressed by two numbers: aa/bb beginning

with start of contract

  • Incurred period (usually plan year)
  • Claims payment deadline

12/12 12/18 12/24 24/12

June 15, 2017 Subject to Change Without Notice 13

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Key Terms

Run‐Out: time after the incurred period in which claims will be paid‐out under stop‐loss coverage

  • 12/18 has a six month run‐out
  • 12/24 has a 12 month run‐out
  • 12/12 has no run‐out

Terminal Liability Option: provides stop‐loss protection at end of contract

  • Run‐out for policies without run‐out

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Managing Variability

Pure Self‐Funding: Employer replenishes claim fund as claims are paid out Fixed‐Cost Self‐Funding: Employer pays fixed monthly payment regardless of claims paid Fully‐Insured Plans: Employer pays fixed monthly premium regardless of claims paid

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Self-funding Basics: Part II

Traditional Insurance:

  • State‐by‐state plan design
  • Subject to all ACA fees and premium tax

Self‐Funded Program:

  • Can offer one plan nationwide
  • Exempt from some ACA fees and pay

premium tax only on excess‐loss coverage

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Traditional aditional Fully Insur Fully Insured ed Fix Fixed-Cost d-Cost Self-Funded Self-Funded Comprehensive Medical Coverage Fixed Monthly Employer Costs

So far so sim So far so simple le

Fixed‐Cost Self‐Funded

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Can look like traditional health plans

17

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Traditional aditional Fully Insur Fully Insured ed Fix Fixed-Cost Self- d-Cost Self- Funded Funded Protects Employers When Claims Higher Higher Than Expected Who Gets Surplus When Claims Less Less Than Expected Insurer Employer

The Fixed‐Cost Self‐Funded Advantage

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What makes them different makes them better Heads you w eads you win. Tails you don’

  • n. Tails you don’t lose.

t lose.

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PLANS AND UNDERWRITING OVERVIEW

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Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters that improve the health of employees and the bottom line of employers

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Self‐funding with training wheels

  • Safe and comfortable way for clients to

start self‐funding medical coverage Mimics traditional insurance while delivering benefits of self‐funding

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Safe and Simple

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Safe Safe Administrative Services: Meritain Health Stop-Loss Coverage: AM Best Rated “A” or higher Simple Simple 8 PPO Plan Designs: 5 Co-Pay & 3 HSA-compatible 1 Medical Network: Aetna 1 Pharmacy Network: OptumRx 1 Contract Period for each product line

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Fixed-Cost, Self-Funded

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Fix Fixed-Cost d-Cost

  • Level premium payments
  • Composite rates
  • Claim costs advanced if exceed

employer’s payments to-date Self-Funded Self-Funded

  • Employer finances claims
  • Stop-loss coverage caps employer risk

(both specific and aggregate coverage)

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Other Le Other Level vel Pr Premium Plans emium Plans Pr Protect and

  • tect and

Secur Secure Plans Plans Fixed Monthly Costs Claim Surplus Refund Partial-to-100% Partial-to-100% 100% 100% Offer Refund Assisters Refund AssistersSM

?

Our Plans vs Traditional Level Premium Plans

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Why Refund Assisters Matter

All level-funded plans offer

  • ffer the chance to

earn claim surplus refunds The Protect and Secure Plans helps deliver deliver them

June 15, 2017 Subject to Change Without Notice 25

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Refund Assisters: Wellness

Wellness rewards for employees and spouses

  • $100 reward for annual preventive exam
  • $100 reward chronic condition program

Wellness campaign assistance Smoking cessation programs

Provided through Healthy Merits, Meritain Health for Life, and Disease Management administered by Meritain Health

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Refund Assisters: Chronic Condition Reward Program

$25 each quarter employee or spouse complies with treatment and prescription protocols for: Asthma Hyperlipidemia (high cholesterol) COPD Congestive Heart Failure Diabetes Coronary Artery Disease Hypertension

Members must be in compliance for all three months in a quarter. Members may qualify for multiple chronic rewards.

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A low‐cost, quality alternative to an in‐office doctor visit that’s convenient, private, and fast using board certified, U.S.‐based physicians.

Refund Assisters: Telemedicine

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Refund Assisters: Expense Review

Actuaries and former insurance executives review overall claim payments including:

  • Payment timeliness review
  • Subrogation
  • Pharmacy data review
  • Medicare‐primary claims
  • Claim audit monitoring

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Benefits: HSAs

HSA 3000 HSA 4000 HSA 5000 Deductibles $3,000 $4,000 $5,000 Annual Max $5,000 $5,500 $6,000 Family 2x Co‐Insurance 80/20 Office Visits Primary and Specialty: 20% / Telemedicine: $10 Prescriptions In‐Network Only Apply to medical deductible and out‐of‐pocket maximums Generic $10 Preferred Brand $35 Non‐Formulary 50% Specialty 35% up to $300 co‐pay per prescription

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Benefits: Co-Pay Plans

Co‐Pay 500 Co‐Pay 1000 Co‐Pay 2000 Co‐Pay 3000 Co‐Pay 4000 Deductibles $500 $1,000 $2,000 $3,000 $4,000 Annual Max $1,500 $3,000 $4,000 $5,000 $6,000 Family 2x Co‐Insurance 90/10 80/20 Office Visit Primary Care: $25 / Specialty: $50 / Telemedicine: $10 Prescriptions In‐Network Only Apply to medical deductible and out‐of‐pocket maximums Generic $10 Brand $35 Non‐Formulary 50% Specialty 35% up to $300 co‐pay per prescription

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Additional Features

Contract Periods Protect Plans Secure Plans First Year 12/18 12/12 Renewal Years 12/18 24/12 Terminal Liability Option None 6 months Specific Accumulator Medical Yes Yes Prescription No, unless requested Yes

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Participation Requirements

Participation Protect Plans Secure Plans Groups up to 50 employees 75% 75% Groups 51+ employees 60% 60% Factors Employees with other medical coverage not considered eligible 51% with proof of spousal waivers HMO Combination Available Yes Factors Employees enrolling in HMO are not considered eligible employees Employees enrolling in HMO are considered eligible employees Employee Choice Plans available Fewer than 40 employees: up to four plans 40 or more employees: up to eight plans

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Underwriting: Availability

Geography Protect Plans Secure Plans States All except New York All except Washington Group Size Minimum State law and carrier policy Maximum No limit, but unlikely above 200 employees Aetna Takeover Clients of Aetna or subsidiaries Not eligible to quote without Aetna approval Retirees Group size 20+ employees 20+ employees Maximum percent retirees 10% 15% of all retirees 10% non‐Medicare retirees Eligible as employee class Yes NA Disclosure Prior to underwriting Prior to underwriting

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Protect Plans: Getting Quotes, Submitting Sales

Quotes: manual rates or

  • Claims history* preferred
  • 150+ employees: claims history required

Enrollment: individual health questions or

  • Claims history
  • 150+ employees: claims history required

Methods:

  • Interactive PDF, telephone or online (FormFire

preferred)

* Prefer prior two years of claims, coverage, enrollment and shock claims

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Secure Plans: Getting Quotes, Submitting Sales

Quotes: manual rates or

  • Claims history* preferred
  • Current and renewal rates

Enrollment: individual health questions or

  • Claims history
  • Current or renewal rates

Methods:

  • Interactive PDF or online (Easy App Online preferred)

* Prefer prior two years of claims, coverage, enrollment and shock claims

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THE TEAM

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Reliable Administration

Meritain Health, an Aetna company

  • One of nation’s largest third party administrators
  • Handles operational aspects including
  • Enrollment
  • Billing
  • Customer services
  • Claims
  • Compensation

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Broad, Strong Networks

Aetna Choice POS* II (Open Access) National coverage

  • 5,500+ hospitals
  • 630,000+ physicians and specialists

* Protect Plans are PPOs

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Broad, Strong Networks

OptumRx pharmacy benefit management using the Catamaran network Includes community pharmacies plus most chains

  • Costco, CVS, Duane Reed, Medicine Shoppe,

Rite Aid, Target, Walgreen’s, Wal‐Mart and many supermarkets

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Protect Plans: Dependable Stop-Loss Coverage

Stable and proven excess‐loss carriers

  • Carrier varies by group size and/or state
  • A.M. Best‐rated carriers with deep

experience providing excess‐loss coverage

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Secure Plans: Dependable Stop-Loss Coverage

ACE American Insurance Company

  • A.M. Best‐rated A++ (Superior)

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Protect Plans: Experienced, Fair Underwriting

The Strategic Underwriting Solutions LLC* team assures fair pricing and their relationship with leading stop‐loss carriers results in a seamless experience for employers Responsible for:

  • Quoting
  • Underwriting
  • Policy issuance
  • Stop‐loss claim services

* In California SUS does business as Strategic & Innovative Insurance Solutions, LLC

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Secure Plans: Experienced, Fair Underwriting

The Ethos Underwriting Services team assures fair pricing and their relationship through ACE American in a seamless experience for employers Responsible for:

  • Quoting
  • Underwriting
  • Policy issuance
  • Stop‐loss claim services

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Insurgency Benefits

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Alan Katz

Principal

AKatz@InsurgencyBenefits.com

Trei Wild Principal

TWild@InsurgencyBenefits.com

Mark Gastineau

Principal

MGastineau@InsurgencyBenefits.com

Insur Insurgency Benefits ency Benefits is responsible for plan design, program oversight and coordination, sales support, marketing, training, and expense review

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RESOURCES

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Protect Plans: Resources

Info@ProtectPlans.Info Quote@ProtectPlans.Info Enroll@ProtectPlans.Info

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www.ProtectPlans.Info

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Secure Plans: Resources

Info@SecurePlans.Info Quote@SecurePlans.Info Enroll@SecurePlans.Info

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www.SecurePlans.Info

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Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters

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APPENDIX: ACA REPORT DATA, SPECIAL CONSIDERATION INDUSTRIES AND WORK FLOW

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Subject to Change Without Notice

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New Group Implementation

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Event Event Anticipated and Appr Anticipated and Approximate imate Timeline Timeline Welcome email to client to set-up Welcome Call 5 business days from receipt of complete enrollment package Temporary medical ID sent (no Rx information) 2 business days from Welcome Call New members in Meritain Health System 5 business days from Welcome Email Permanent ID cards mailed to employer (includes Rx info) 10 business days from Welcome Email (+ 2 days for delivery) Prescription benefits in system 15 business days from time drug card set-up documents submitted to OptumRx Healthcare Bluebook 45-to-60 days

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A Word About ACA Fees

ACA Fees are not included in monthly payments

  • Patient‐Centered Outcomes Research Institute

(PCORI) Fees

  • Transitional Reinsurance Program (TRP) Fee

Meritain facilitates fee calculation and payment

  • Employer is responsible for funding these fees
  • utside of the fixed monthly payments

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May be required to submit more information to be considered or may be considered ineligible

  • Asbestos Products
  • Commercial Sports
  • Explosives
  • Legal Services
  • Long Haul Trucking
  • Medical Services
  • Metal/Coal Mining
  • Oil and Gas Exploration/Extraction
  • Religious Organizations
  • Tobacco Stores and Stands/Tobacco Products

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Workflow: Quoting

  • Company name, address and industry
  • Effective date desired
  • Employee census
  • Birthdate, gender, dependents, zip code
  • For preliminary rate include:
  • Claims and census history for past

24 months if available

  • Shock loss history if available

Please see Quoting Checklist and Underwriting Guide for complete details

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Workflow: Enrollment

  • Employer and Employee enrollment forms
  • Signed rating sheet(s)
  • Current carrier billing
  • First month’s premium and claims funding
  • PHI Release
  • Wage & Tax Report
  • COBRA information if appropriate
  • Claims history if available
  • Covering 60‐days prior to effective date
  • Final employer disclosure

Please see Submission Checklist and Underwriting Guide for complete details

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