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

Transcription

1 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

2 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

3 What Employers Want Something different and better An advantage Something like fixed cost, self funded plans June 15, 2017 Subject to Change Without Notice 3

4 Two Solutions Insurgency Benefits offers two safe and simple, fixed cost self funded medical coverage programs June 15, 2017 Subject to Change Without Notice 4

5 Self-Funded Made Simple Self Funded can be complicated but it doesn t have to be June 15, 2017 Subject to Change Without Notice 5

6 Why Consider Self-Funding Claims lower than expected = refund Claims higher than expected = stop loss Heads clients win. Tails they don t lose It s that simple June 15, 2017 Subject to Change Without Notice 6

7 Agenda 1. Self Funded Basics and Key Terms 2. Plans and Underwriting Overview 3. Resources 4. The Team 5. Questions and Answers June 15, 2017 Subject to Change Without Notice 7

8 SELF FUNDING BASICS AND KEY TERMS June 15, 2017 Subject to Change Without Notice 8

9 Self-Funded Basics: Part I Traditional Insurance: State regulation Insurer pays claims keeps surplus Self Funded Programs: Federal regulation Employer pays claims keeps surplus June 15, 2017 Subject to Change Without Notice 9

10 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 June 15, 2017 Subject to Change Without Notice 10

11 Key Terms Claims Fund: money set aside by employers to pay claims Claims Surplus: money remaining in the claims fund after the contract period June 15, 2017 Subject to Change Without Notice 11

12 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 June 15, 2017 Subject to Change Without Notice 12

13 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

14 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 June 15, 2017 Subject to Change Without Notice 14

15 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 June 15, 2017 Subject to Change Without Notice 15

16 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 June 15, 2017 Subject to Change Without Notice 16

17 Fixed Cost Self Funded Can look like traditional health plans Comprehensive Medical Coverage Fixed Monthly Employer Costs Traditional Fully Insured So far so simple Fixed-Cost Self-Funded June 15, 2017 Subject to Change Without Notice 17

18 The Fixed Cost Self Funded Advantage What makes them different makes them better Protects Employers When Claims Higher Than Expected Who Gets Surplus When Claims Less Than Expected Traditional Fully Insured Insurer Fixed-Cost Self- Funded Employer Heads you win. Tails you don t lose. June 15, 2017 Subject to Change Without Notice 18

19 PLANS AND UNDERWRITING OVERVIEW June 15, 2017 Subject to Change Without Notice 19

20 Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters that improve the health of employees and the bottom line of employers June 15, 2017 Subject to Change Without Notice 20

21 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 June 15, 2017 Subject to Change Without Notice 21

22 Safe and Simple Safe Administrative Services: Meritain Health Stop-Loss Coverage: AM Best Rated A or higher 8 PPO Plan Designs: 5 Co-Pay & 3 HSA-compatible Simple 1 Medical Network: Aetna 1 Pharmacy Network: OptumRx 1 Contract Period for each product line June 15, 2017 Subject to Change Without Notice 22

23 Fixed-Cost, Self-Funded Fixed-Cost Level premium payments Composite rates Claim costs advanced if exceed employer s payments to-date Self-Funded Employer finances claims Stop-loss coverage caps employer risk (both specific and aggregate coverage) June 15, 2017 Subject to Change Without Notice 23

24 Our Plans vs Traditional Level Premium Plans Other Level Premium Plans Protect and Secure Plans Fixed Monthly Costs Claim Surplus Refund Partial-to-100% 100% Offer Refund Assisters SM? June 15, 2017 Subject to Change Without Notice 24

25 Why Refund Assisters Matter All level-funded plans offer the chance to earn claim surplus refunds The Protect and Secure Plans helps deliver them June 15, 2017 Subject to Change Without Notice 25

26 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 June 15, 2017 Subject to Change Without Notice 26

27 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. June 15, 2017 Subject to Change Without Notice 27

28 Refund Assisters: Telemedicine A low cost, quality alternative to an in office doctor visit that s convenient, private, and fast using board certified, U.S. based physicians. June 15, 2017 Subject to Change Without Notice 28

29 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 June 15, 2017 Subject to Change Without Notice 29

30 Benefits: HSAs HSA 3000 HSA 4000 HSA 5000 Deductibles $3,000 $4,000 $5,000 Annual Max $5,000 $5,500 $6,000 Family 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 2x 35% up to $300 co pay per prescription June 15, 2017 Subject to Change Without Notice 30

31 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 PP: 80/20 Co Insurance 80/20 SP: 90/10 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 2x 35% up to $300 co pay per prescription June 15, 2017 Subject to Change Without Notice 31

32 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 June 15, 2017 Subject to Change Without Notice 32

33 Participation Requirements Participation Protect Plans Secure Plans Groups up to 50 employees 75% 75% Groups 51+ employees 60% 60% Factors HMO Combination Available Factors Employee Choice Plans available Employees with other medical coverage not considered eligible Employees enrolling in HMO are not considered eligible employees Yes 51% with proof of spousal waivers Employees enrolling in HMO are considered eligible employees Fewer than 40 employees: up to four plans 40 or more employees: up to eight plans June 15, 2017 Subject to Change Without Notice 33

34 Underwriting: Availability Geography Protect Plans Secure Plans States All except New York All except Washington Group Size Minimum Maximum Aetna Takeover Clients of Aetna or subsidiaries Retirees State law and carrier policy No limit, but unlikely above 200 employees Not eligible to quote without Aetna approval 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 June 15, 2017 Subject to Change Without Notice 34

35 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 June 15, 2017 Subject to Change Without Notice 35

36 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 June 15, 2017 Subject to Change Without Notice 36

37 THE TEAM June 15, 2017 Subject to Change Without Notice 37

38 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 June 15, 2017 Subject to Change Without Notice 38

39 Broad, Strong Networks Aetna Choice POS * II (Open Access) National coverage 5,500+ hospitals 630,000+ physicians and specialists * Protect Plans are PPOs June 15, 2017 Subject to Change Without Notice 39

40 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 June 15, 2017 Subject to Change Without Notice 40

41 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 June 15, 2017 Subject to Change Without Notice 41

42 Secure Plans: Dependable Stop-Loss Coverage ACE American Insurance Company A.M. Best rated A++ (Superior) June 15, 2017 Subject to Change Without Notice 42

43 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 June 15, 2017 Subject to Change Without Notice 43

44 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 June 15, 2017 Subject to Change Without Notice 44

45 Insurgency Benefits Insurgency Benefits is responsible for plan design, program oversight and coordination, sales support, marketing, training, and expense review Mark Gastineau Principal Alan Katz Principal Trei Wild Principal June 15, 2017 Subject to Change Without Notice 45

46 RESOURCES June 15, 2017 Subject to Change Without Notice 46

47 Protect Plans: Resources June 15, 2017 Subject to Change Without Notice 47

48 Secure Plans: Resources June 15, 2017 Subject to Change Without Notice 48

49 Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters June 15, 2017 Subject to Change Without Notice 49

50 APPENDIX: ACA REPORT DATA, SPECIAL CONSIDERATION INDUSTRIES AND WORK FLOW June 15, 2017 Subject to Change Without Notice 50

51 New Group Implementation Event Welcome to client to set-up Welcome Call Temporary medical ID sent (no Rx information) New members in Meritain Health System Permanent ID cards mailed to employer (includes Rx info) Prescription benefits in system Healthcare Bluebook Anticipated and Approximate Timeline 5 business days from receipt of complete enrollment package 2 business days from Welcome Call 5 business days from Welcome 10 business days from Welcome (+ 2 days for delivery) 15 business days from time drug card set-up documents submitted to OptumRx 45-to-60 days June 15, 2017 Subject to Change Without Notice 51

52 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 outside of the fixed monthly payments June 15, 2017 Subject to Change Without Notice 52

53 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 June 15, 2017 Subject to Change Without Notice 53

54 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 June 15, 2017 Subject to Change Without Notice 54

55 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 June 15, 2017 Subject to Change Without Notice 55