Safe and Simple Fixed-Cost Self-Funded Medical Coverage Plus Refund - - PowerPoint PPT Presentation

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Safe and Simple Fixed-Cost Self-Funded Medical Coverage Plus Refund - - PowerPoint PPT Presentation

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Safe and Simple Fixed-Cost Self-Funded Medical Coverage Plus Refund Assisters Overview March 1, 2016 March 1, 2016 1 Subject to Change Without Notice Disclaimer 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

March 1, 2016

March 1, 2016

Subject to Change Without Notice

1

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SLIDE 2

Disclaimer 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, it’s as accurate as possible. If it’s wrong we apologize, but it’s not binding.

March 1, 2016 Subject to Change Without Notice 2

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The Reality The Reality

Employers are not only looking for something … and better They need something different and better Something that offers them an advantage The They’re looking for fix e looking for fixed-cost, self-funded plans d-cost, self-funded plans with e with excess loss pr cess loss protection

  • tection

March 1, 2016 Subject to Change Without Notice 3

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Self-Funded Made Simple Self-Funded Made Simple

Self-Funded can be complicated … Self-Funded can be complicated … … … but it doesn but it doesn’t have to be t have to be The Pr The Protect Plans ar

  • tect Plans are all about Simple

e all about Simple

March 1, 2016 Subject to Change Without Notice 4

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The Pr The Protect Plans ar

  • tect Plans are all about Simple

e all about Simple

When claims are lower than expected, clients get a refund When claims are higher than expected, stop-loss coverage steps in. Heads clients win. Tails they don’t lose. It’s that simple.

March 1, 2016 Subject to Change Without Notice 5

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Agenda Agenda

  • 1. Self-Funded Basics and Key Terms
  • 2. The Protect Plans Overview
  • 3. Resources: www.ProtectPlans.Info
  • 4. The Protect Plans Team
  • 5. SUS and Meritain Health
  • 6. Questions and Answers

March 1, 2016 Subject to Change Without Notice 6

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SELF-FUNDING SELF-FUNDING BASICS AND KEY TERMS SICS AND KEY TERMS

March 1, 2016 Subject to Change Without Notice 7

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Self-Funded Basics: Part I Self-Funded Basics: Part I

Traditional Insur aditional Insurance: nce:

  • State

State regulation

  • Insur

Insurer pays claims – and keeps surplus Self-Funded Pr Self-Funded Progr

  • grams:

ms:

  • Feder

Federal al regulation

  • Emplo

Employer er pays claims – and keeps surplus

March 1, 2016 Subject to Change Without Notice 8

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8 Ke 8 Key T y Terms rms

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

March 1, 2016 Subject to Change Without Notice 9

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Ke Key T y Terms rms

Claims Fund Claims Fund: dollars set aside to cover claims Claims Surplus Claims Surplus: dollars remaining in claims fund after the contract period Stop-Loss or Ex Stop-Loss or Excess Loss Co cess Loss Cover verage ge: protects plan sponsor from excessive claims

  • Specific

Specific: caps claims on any one individual

  • Aggr

Aggregate egate: caps overall claims Attachment Point Attachment Point: the claim amount at which stop-loss coverage kicks-in

March 1, 2016 Subject to Change Without Notice 10

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Ke Key T y Terms rms

Contr Contract Period ct Period: time period during which eligible claims must be incurred and paid for to be covered by the plan

  • Expressed by two number: aa/bb
  • First defines plan year (usually 12)
  • Second defines claim payment deadline

12/12 12/15 12/18 12/24

  • Run-Out

Run-Out: the difference between numbers

  • 12/18 has a six month run-out
  • 12/24 has a 12 month run-out

March 1, 2016 Subject to Change Without Notice 11

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Variability riability

“Pure” Self-Funding:

  • Employer replenishes claim fund as claims

are approved Fixed-Cost Self-Funding:

  • Employer pays fixed monthly payment

regardless of claims paid out Traditional Insurance:

  • Employer pays fixed monthly premium

regardless of claims paid out

March 1, 2016 Subject to Change Without Notice 12

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Self-funding Basics: Part II Self-funding Basics: Part II

Traditional Insur aditional Insurance: nce:

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

Self-Funded Pr Self-Funded Progr

  • gram:

m:

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

premium tax only on excess-loss coverage

March 1, 2016 Subject to Change Without Notice 13

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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

Fix Fixed-Cost Self-Funded d-Cost Self-Funded

March 1, 2016 Subject to Change Without Notice 14

Self-funded plans with stop-loss coverage can look like traditional health plans

14

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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 Fix The Fixed-Cost Self-Funded Advantage d-Cost Self-Funded Advantage

March 1, 2016 Subject to Change Without Notice 15

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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THE PRO THE PROTECT PLANS O ECT PLANS OVERVIEW ERVIEW

March 1, 2016 Subject to Change Without Notice 16

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

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The Pr The Protect Plans Position

  • tect Plans Position

The Protect Plans are next generation fixed-cost self-funded medical plans delivering features that improve the health of employees and the bottom line of employers

March 1, 2016 Subject to Change Without Notice 17

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The Pr The Protect Plans Position

  • tect Plans Position

Self-funding with training wheels

  • A safe and comfortable way for clients to

start self-funding medical coverage Designed to mimic traditional insurance while delivering benefits of self-funding

March 1, 2016 Subject to Change Without Notice 18

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March 1, 2016 Subject to Change Without Notice 19

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

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Safe and Simple Safe and Simple

March 1, 2016 Subject to Change Without Notice 20

Safe Safe Administrative Services: Meritain Health Stop-Loss Coverage: AM Best Rated “A” or higher Simple Simple 7 PPO Plan Designs: 4 Co-Pay & 3 HSA-compatible 1 Medical Network: Aetna 1 Pharmacy Network: Catamaran through OptumRx 1 Contract Period: 12/18

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Fix Fixed-Cost, Self-Funded d-Cost, Self-Funded

March 1, 2016 Subject to Change Without Notice 21

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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Traditional Le aditional Level vel Funded Plans Funded Plans Pr Protect Plans

  • tect Plans

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

?

The Pr The Protect Plans Differ

  • tect Plans Difference

nce

March 1, 2016 Subject to Change Without Notice 22

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Why Refund Assisters Matter Why Refund Assisters Matter

All level-funding and maximum funded plans

  • ffer
  • ffer employers the chance to earn claim

surplus refunds The Protect Plans help deliver deliver on that promise

March 1, 2016 Subject to Change Without Notice 23

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Refund Assisters: W Refund Assisters: Wellness llness

Rewarding employees and spouses taking steps to improve and manage their health

  • $100 reward for completing an annual

biometric screening

  • $100 reward per year ($25 per quarter) for

complying with chronic condition protocols Assist companies with wellness campaigns Smoking cessation programs

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

March 1, 2016 Subject to Change Without Notice 24

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Chr Chronic Condition Re nic Condition Rewar ward Pr d Progr

  • gram

$25 for each quarter in which employee or spouse is in compliance with treatment and prescription protocols for: Asthma Hyperlipidemia (high cholesterol) COPD Congestive Heart Failure Diabetes Coronary Artery Disease Hypertension Member must be in compliance for all three months in a quarter to earn cash reward and may qualify for multiple chronic condition rewards

March 1, 2016 Subject to Change Without Notice 25

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Refund Assisters: T Refund Assisters: Transpar ansparency ency

Provides members meaningful cost and quality information concerning in-network facilities The opportunity: outstanding care and savings for both members and employers

March 1, 2016 Subject to Change Without Notice 26

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Refund Assisters: Expense Re Refund Assisters: Expense Revie view

Actuaries and former insurance executives review overall claim payments including:

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

March 1, 2016 Subject to Change Without Notice 27

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PLAN DESIGNS PLAN DESIGNS AND AND UNDERWRITING UNDERWRITING

March 1, 2016 Subject to Change Without Notice 28

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Pr Protect HSA-Compatible Plans

  • tect HSA-Compatible Plans

March 1, 2016 Subject to Change Without Notice 29

Benef Benefits ts

(In-Ne (In-Network) k)

Protect HS

  • tect HSA 3

A 3000 000 Protect

  • tect HSA 4000

HSA 4000 Pr Protect

  • tect HSA 5000

HSA 5000

Lifetime Max Unlimited Deductible

(single/family)

$3,000 /$6,000 $4,000 / $8,000 $5,000 / $10,000 Annual Max (single/family) $5,000 / $10,000 $5,500 / $11,000 $6,000 / $12,000 Office Visits and Professional 20% Hospital 20% Lab & X-rays 20% Prescription

(In-network only)

Prescription costs apply to medical deductible and

  • ut-of-pocket maximums

Generic $10 Preferred Brand $35 Non-Formulary 50% Specialty 35% up to $300 co-pay per prescription

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Pr Protect Co-Pay Plans

  • tect Co-Pay Plans

March 1, 2016 Subject to Change Without Notice 30

Benef Benefits ts

(In-Ne (In-Network) k)

Protect

  • tect

Co-Pay 500 Co-Pay 500 Protect

  • tect

Co-Pay Co-Pay 1000 1000 Protect

  • tect

Co-Pay 2000 Co-Pay 2000 Protect

  • tect

Co-Pay Co-Pay 4000 4000

Lifetime Max Unlimited Deductible

(single/family)

$500 /$1,000 $1,000/$2,000 $2,000 / $4,000 $4,000 / $8,000 Annual Max

(single/family)

$1,500 / $3,000 $3,000 /$5,000 $4,000 / $6,000 $6,000 / $12,000 Office Visits Primary Care: $25 / Specialty Care: $50 Lab & X-Rays 20% Hospital and Professional 20% Prescription

(n-network only)

Separate deductible of: $200 single / $400 family) Generic $10 (deductible waived) Preferred Brand $35 Non-Formulary 50% Specialty 35% up to $300 co-pay per prescription

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A W A Word About Pr About Prescription Claims escription Claims

Medical claim costs capped by both specific and aggregate stop-loss limits Prescription claim costs capped by aggregate stop-loss limit only

March 1, 2016 Subject to Change Without Notice 31

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Underwriting: Availability Underwriting: Availability

Geogr Geography: phy:

  • All states (except New York)
  • Some industries subject to additional review

Gr Group Size:

  • up Size:
  • Minimum: state law and carrier policy
  • Maximum: 250+ employees

March 1, 2016 Subject to Change Without Notice 32

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Underwriting: Special Consider Underwriting: Special Consideration ation

Aetna T Aetna Takeover: er:

  • Current Aetna clients, including clients of

subsidiaries, are not eligible to quote

  • Extenuating circumstances must be approved

in advance by Aetna or the subsidiary Retir Retirees: ees:

  • Groups of 20+ employees: retirees may be

considered an employee class

  • Pre-approval required by underwriting
  • No more than 10% of those enrolling may be

retirees

March 1, 2016 Subject to Change Without Notice 33

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Underwriting: Participation Underwriting: Participation

Participation Requir Participation Requirements: ements:

  • Groups of up to 50 eligible employees: 75%

75%

  • Groups of 51+ eligible employees: 60%

60% Eligible Emplo Eligible Employees: ees:

  • Eligible employees are full-time employees

without qualifying coverage elsewhere

(generally, other major medical coverage)

March 1, 2016 Subject to Change Without Notice 34

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Underwriting: Emplo Underwriting: Employer Options er Options

March 1, 2016 Subject to Change Without Notice 35

HMO Combination: HMO Combination: HMOs may be offered with The Protect Plans

  • Participation requirements apply
  • Employees enrolling in HMO are not

considered eligible employees Emplo Employee Choice: ee Choice: Employers may offer any combination of The Protect Plans

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SLIDE 36

Claims History Requir Claims History Required ed

Enr Enrolling lling Emplo Employees ees Quoting Quoting Enr Enrolling lling Up to 150 Not Required

But enables more accurate quote

Not Required

But individual health questions waived when provided

151 or more Required

Explanation needed if unavailable

Required

Explanation needed if unavailable

March 1, 2016 Subject to Change Without Notice 36

Preferred claims information: prior two years of claims, coverage, enrollment and shock claims Telephone enrollment and underwriting is available at no cost

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Ne New Gr w Group Implementation

  • up Implementation

March 1, 2016 Subject to Change Without Notice 37

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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RESOURCES RESOURCES

March 1, 2016 Subject to Change Without Notice 38

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SLIDE 39

March 1, 2016 Subject to Change Without Notice 39

www www.Pr .ProtectPlans.Info tectPlans.Info

www www.Pr ProtectPlans.Info

  • tectPlans.Info
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Ke Key Emails y Emails

Info@Pr Info@ProtectPlans.Info tectPlans.Info Quote@Pr Quote@ProtectPlans.Info

  • tectPlans.Info

Enr Enroll@Pr ll@ProtectPlans.Info

  • tectPlans.Info

March 1, 2016 Subject to Change Without Notice 40

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THE TEAM THE TEAM

March 1, 2016 Subject to Change Without Notice 41

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Reliable Administr Reliable Administration ation

Meritain Health Meritain Health, an Aetna company

  • One of the nation’s largest third party

administrators

  • Handles all operational aspects including
  • Enrollment processing
  • Billing
  • Customer services
  • Claims administration
  • Compensation

March 1, 2016 Subject to Change Without Notice 42

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SLIDE 43

Br Broad, Str

  • ad, Strong Networks

ng Networks

Aetna Choice POS Aetna Choice POS* II (Open II (Open Access) Access) National coverage

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

OptumRx OptumRx pharmacy benefit management using the Catamar Catamaran network Community pharmacies plus most chains including Costco, CVS, Duane Reed, Medicine Shoppe, Rite Aid, Target, Walgreen’s, Wal-Mart and many supermarkets

* Protect Plans are PPOs

March 1, 2016 Subject to Change Without Notice 43

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Dependable Stop-Loss Co Dependable Stop-Loss Cover verage age

Stable and proven excess-loss carriers

  • Carrier varies by group size and/or state
  • All are A.M. Best “A” rated carriers or better
  • All with deep experience providing excess-

loss coverage

March 1, 2016 Subject to Change Without Notice 44

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Experienced, Fair Underwriting Experienced, Fair Underwriting

The Str Strategic Underwriting Solutions LL tegic 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

March 1, 2016 Subject to Change Without Notice 45

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Insur Insurgency Benefits gency Benefits

March 1, 2016 Subject to Change Without Notice 46

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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The Pr The Protect Plans

  • tect Plans

Safe and Simple, Fixed-Cost Self-Funded Medical Coverage with Refund Assisters Next generation fixed-cost self-funded medical plans delivering features that improve the health of employees and the bottom line of employers

March 1, 2016 Subject to Change Without Notice 47

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March 1, 2016 Subject to Change Without Notice 48

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

www www.Pr .ProtectPlans.Info tectPlans.Info

Info@Pr Info@ProtectPlans tectPlans.Info Info Quote@Pr Quote@ProtectPlans

  • tectPlans.Inf

.Info

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APPENDIX: APPENDIX: ACA REPORT A REPORT, SPECIAL C SPECIAL CONSIDERA NSIDERATION INDUSTRIES ION INDUSTRIES AND AND WO WORK F FLOW OW

March 1, 2016 Subject to Change Without Notice 49

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A W A Word About A About ACA Reports A Reports

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

March 1, 2016 Subject to Change Without Notice 50

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May b be r required t to s submit m more i information t to be consider be considered or may be consider ed or may be considered ineligible ed 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

March 1, 2016 Subject to Change Without Notice 51

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Workflo rkflow: Quoting w: 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

March 1, 2016 Subject to Change Without Notice 52

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Workflo rkflow: Enr w: Enrollment llment

  • 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

March 1, 2016 Subject to Change Without Notice 53