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 October 16, 2015 October 16, 2015 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 stoploss 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. October 16, 2015 Subject to Change Without Notice 2

3 The Reality In today s market employers are looking for something different and better Offering the same-old, same-old isn t enough It s time to consider fixed-cost, self-funded plans with excess loss protection October 16, 2015 Subject to Change Without Notice 3

4 Self-Funded Made Simple Self-Funded can be complicated but it doesn t have to be The Protect Plans are all about Simple October 16, 2015 Subject to Change Without Notice 4

5 Agenda 1. Self-Funded Basics and Key Terms 2. The Protect Plans Overview 3. Resources: 4. The Protect Plans Team 5. SUS and Meritain Health 6. Questions and Answers October 16, 2015 Subject to Change Without Notice 5

6 SELF-FUNDING BASICS AND KEY TERMS October 16, 2015 Subject to Change Without Notice 6

7 Self-Funded Basics: Part I Traditional Insurance: State regulation Insurer pays claims and keeps surplus Self-Funded Programs: Federal regulation Employer pays claims and keeps surplus October 16, 2015 Subject to Change Without Notice 7

8 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 October 16, 2015 Subject to Change Without Notice 8

9 Key Terms Claims Fund: dollars set aside to cover claims Claims Surplus: dollars remaining in claims fund after the contract period Stop-Loss or Excess Loss Coverage: protects plan sponsor 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 October 16, 2015 Subject to Change Without Notice 9

10 Key Terms Contract 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: the difference between numbers 12/18 has a six month run-out 12/24 has a 12 month run-out October 16, 2015 Subject to Change Without Notice 10

11 Variability 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 October 16, 2015 Subject to Change Without Notice 11

12 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 pays premium tax only on excess-loss coverage October 16, 2015 Subject to Change Without Notice 12

13 Fixed-Cost Self-Funded Self-funded plans with stop-loss coverage can look like traditional health plans Comprehensive Medical Coverage Fixed Monthly Employer Costs Protects Employers When Claims Higher Than Expected Traditional Fully Insured Fixed-Cost Self-Funded October 16, 2015 Subject to Change Without Notice 13

14 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. October 16, 2015 Subject to Change Without Notice 14

15 THE PROTECT PLANS OVERVIEW Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters October 16, 2015 Subject to Change Without Notice 15

16 The Protect 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 October 16, 2015 Subject to Change Without Notice 16

17 The Protect Plans Position Self-funding with training wheels A safe and comfortable way for clients to test drive self-funding Designed to mimic traditional coverage while delivering benefits of self-funding October 16, 2015 Subject to Change Without Notice 17

18 Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters October 16, 2015 Subject to Change Without Notice 18

19 Safe and Simple Safe Simple Administrative Services Stop-Loss Coverage PPO Plan Designs Medical Network Pharmacy Network Meritain Health AM Best Rated A or higher 4 Co-Pay 3 HSA-compatible Aetna Catamaran Contract Period 12/18 October 16, 2015 Subject to Change Without Notice 19

20 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) October 16, 2015 Subject to Change Without Notice 20

21 The Protect Plans Difference Traditional Level Funded Plans Protect Plans Fixed Monthly Costs Claim Surplus Refund Partial-to-100% 100% Offer Refund Assisters SM? October 16, 2015 Subject to Change Without Notice 21

22 Why Refund Assisters Matter All level-funding and maximum funded plans offer employers the chance to earn claim surplus refunds The Protect Plans help deliver on that promise October 16, 2015 Subject to Change Without Notice 22

23 Refund Assisters: Wellness 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 October 16, 2015 Subject to Change Without Notice 23

24 Chronic Condition Reward Program $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 October 16, 2015 Subject to Change Without Notice 24

25 Refund Assisters: Transparency Provides members meaningful cost and quality information concerning in-network facilities The opportunity: outstanding care and savings for both members and employers October 16, 2015 Subject to Change Without Notice 25

26 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 October 16, 2015 Subject to Change Without Notice 26

27 PLAN DESIGNS AND UNDERWRITING October 16, 2015 Subject to Change Without Notice 27

28 Protect HSA-Compatible Plans Benefits (In-Network) Lifetime Max Deductible (single/family) Annual Max (single/family) Office Visits and Professional Protect HSA 3000 Protect HSA 4000 Protect HSA 5000 Unlimited $3,000 /$6,000 $4,000 / $8,000 $5,000 / $10,000 $5,000 / $10,000 $5,500 / $11,000 $6,000 / $12,000 20% Hospital 20% Lab & X-rays 20% Prescription (In-network only) Prescription costs 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 October 16, 2015 Subject to Change Without Notice 28

29 Protect Co-Pay Plans Benefits (In-Network) Protect Co-Pay 500 Protect Co-Pay 1000 Protect Co-Pay 2000 Protect Co-Pay 4000 Lifetime Max Deductible (single/family) Annual Max (single/family) Unlimited $500 /$1,000 $1,000/$2,000 $2,000 / $4,000 $4,000 / $8,000 $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 Prescription (n-network only) Generic 20% Separate deductible of: $200 single / $400 family) $10 (deductible waived) Preferred Brand $35 Non-Formulary 50% Specialty 35% up to $300 co-pay per prescription October 16, 2015 Subject to Change Without Notice 29

30 A Word About Prescription Claims Medical claim costs capped by both specific and aggregate stop-loss limits Prescription claim costs capped by aggregate stop-loss limit only October 16, 2015 Subject to Change Without Notice 30

31 Underwriting: Availability Geography: All states (except New York) Some industries subject to additional review Group Size: Minimum: state law and carrier policy Maximum: 250+ employees October 16, 2015 Subject to Change Without Notice 31

32 Underwriting: Special Consideration Aetna Takeover: Current Aetna clients, including subsidiary clients, are not eligible to quote Extenuating circumstances must be approved in advance by Aetna or the subsidiary Retirees: 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 October 16, 2015 Subject to Change Without Notice 32

33 Underwriting: Participation Participation Requirements: Groups of up to 50 eligible employees: 75% Groups of 51+ eligible employees: 60% Eligible Employees: Eligible employees are full-time employees without qualifying coverage elsewhere (generally, other major medical coverage) October 16, 2015 Subject to Change Without Notice 33

34 Underwriting: Employer Options HMO Combination: HMOs may be offered with The Protect Plans Participation requirements apply Employees enrolling in HMO are not considered eligible employees Employee Choice: Employers may offer any combination of The Protect Plans October 16, 2015 Subject to Change Without Notice 34

35 Claims History Required Enrolling Employees Quoting Enrolling Up to 150 Not Required But enables more accurate quote 151 or more Required Explanation needed if unavailable Not Required But individual health questions waived when provided Required Explanation needed if unavailable Preferred claims information: prior two years of claims, coverage, enrollment and shock claims Telephone underwriting available for enrolling groups October 16, 2015 Subject to Change Without Notice 35

36 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 (+ two days for delivery) 15 business days from time drug card setup documents submitted to Scrip World 45-to-60 days October 16, 2015 Subject to Change Without Notice 36

37 RESOURCES October 16, 2015 Subject to Change Without Notice 37

38 October 16, 2015 Subject to Change Without Notice 38

39 Key s October 16, 2015 Subject to Change Without Notice 39

40 THE TEAM October 16, 2015 Subject to Change Without Notice 40

41 Reliable Administration 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 October 16, 2015 Subject to Change Without Notice 41

42 Broad, Strong Networks Aetna Choice POS * II (Open Access) National coverage 5,500+ hospitals 630,000+ physicians and specialists Scrip World pharmacy benefit management using the 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 October 16, 2015 Subject to Change Without Notice 42

43 Dependable Stop-Loss Coverage 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 excessloss coverage October 16, 2015 Subject to Change Without Notice 43

44 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 October 16, 2015 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 October 16, 2015 Subject to Change Without Notice 45

46 SUS AND MERITAIN HEALTH October 16, 2015 Subject to Change Without Notice 46

47 The Protect Plans In California SUS does business as Strategic & Innovative Insurance Solutions, LLC October 16, 2015 Subject to Change Without Notice 47

48 The Protect Plans October 16, 2015 Subject to Change Without Notice 48

49 QUESTIONS October 16, 2015 Subject to Change Without Notice 49

50 The Protect 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 October 16, 2015 Subject to Change Without Notice 50

51 Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters October 16, 2015 Subject to Change Without Notice 51

52 APPENDIX: ACA REPORT, SPECIAL CONSIDERATION INDUSTRIES AND WORK FLOW October 16, 2015 Subject to Change Without Notice 52

53 A Word About ACA 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 outside of the fixed monthly payments October 16, 2015 Subject to Change Without Notice 53

54 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 October 16, 2015 Subject to Change Without Notice 54

55 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 October 16, 2015 Subject to Change Without Notice 55

56 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 Final employer disclosure Please see Submission Checklist and Underwriting Guide for complete details October 16, 2015 Subject to Change Without Notice 56