What Are the Details of Health Benefit Coverage?

Transcription

1 What Are the Details of Health Benefit Coverage? #E-04 Larry S. Chapman MPH President and CEO The Chapman Institute Seattle, WA (206) Module Length = 65 minutes 1 Problem Statement Need to understand how health benefits work and how they relate to worksite wellness programming 2 1

2 Agenda Brief history of health benefits What you need to know When you need to know it Getting what you need Summary of main points Q & A session Self-quiz Download attachment 3 Health Benefit Costs Continue to Increase Total health benefit cost change vs. workers earnings and general CPI, Source: Mercer Employer Health Care Survey,

3 Brief History of Health Benefits Montgomery Ward Adopts Insurance for employees The "Baylor Plan" Created Internal Revenue Act - tax exclusion for WC National War Labor Board Rules Kaiser Health Plan Opens to Public 1948 McCarran-Ferguson Act gives states broad power to regulate insurance Internal Revenue Act Becomes Law tax exclusion for health benefits Medicare and Medicaid Firestone Self-Insures Health Benefits 5 Brief History of Health Benefits (Continued) Health Maintenance Organization Act Becomes Law 1974 Employee Retirement Income Security Act of 1974 (ERISA) 1986 Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) Health Insurance Portability and Accountability Act Becomes Law 1996 Mental Health Parity Act 1996 Newborns' and Mothers' Health Protection Act CHIP and Medicare +Choice Established 2010 Patient Protection and Affordable Care Act of 2010 Passed into Law 3

4 Overview of Health Benefit Coverage: 2009 Coverage Medium & Large Employers State & Local Government Small Private Establishments Health Insurance 62% 83% 42% Dental Insurance 49% 53% 23% Vision Care 31% 34% 13% Rx 60% 82% 41% Source: Employee Benefit Research Institute, EBRI Databook on Employee Benefits, Chapter 4: Participation in Employee Benefit programs, Costs of Employee Health Average Annual Cost Per Employee in 2010 Total = $34,918 $10,122 Health Plan $21,256 $1,757 Sick Leave Workers Comp Disability $672 $1,111 Presenteeism Source: Goetzel, JOEM, (2004) data adjusted to 2010 by Mercer Employer Survey Results and by Collins Presenteeism study (2005) of Dow Chemical that was used for determining the Presenteeism cost. 8 4

5 Health Plan Basics Coverage Issues Eligibility Plan effective dates Covered benefits Claims procedures Exclusions Limitations HCM requirements Continuation Appeal process Definitions SPD Example INTRODUCTION... 7 PLAN HIGHLIGHTS... 7 ELIGIBILITY... 9 HOW THE PLAN WORKS ENROLLING IN YOUR PLAN BENEFITS WHAT HAPPENS TO YOUR BENEFITS IN SPECIAL SITUATIONS HEALTHWAVES EMPLOYEE WELLNESS PROGRAM MEDICAL OVERVIEW PREFERRED PROVIDER ORGANIZATION (PPO) MEDICAL PLAN OPTIONS EXCLUSIVE PROVIDER ORGANIZATION (EPO) MEDICAL PLAN OPTIONS HEALTH MAINTENANCE ORGANIZATION (HMO) MEDICAL PLAN OPTIONS ANTHEM CONSUMER DRIVEN HEALTH PLAN (CDHP) AETNA GLOBAL BENEFITS PLAN OPTION IF YOU CHOOSE NO MEDICAL COVERAGE LIFETIME MAXIMUM THIRD-PARTY REIMBURSEMENT (RIGHT OF SUBROGATION) ADDITIONAL INFORMATION ABOUT YOUR MEDICAL BENEFITS Medical Plan Options: Large Employer Example Our Company offers the following medical plan options: Preferred PPO Medical Plan Option Premium PPO Medical Plan Option (no new enrollments effective July 1, 2009) Exclusive Provider Organization (EPO) Medical Plan Options, available in many states nationwide Regional EPO Medical Plan Options, if offered in your ZIP code area Regional Health Maintenance Organization (HMO) Medical Plan Options, if offered in your ZIP code area Anthem Consumer Driven Health Plan (CDHP) Aetna Global Benefits Plan option (if you work and live outside the United States) No medical coverage. 10 5

6 Sample of Typical Covered Services Acupuncture and Acupressure Allergy Care Injections and Tests Ambulance Anesthesia Blood Transfusions Breast Reconstruction Coverage Cardiac Rehabilitation Therapy Chiropractic Dental Services and Oral Surgery Diagnostic Lab Services and X-rays Durable Medical Equipment Emergency Room Care Family Planning Hearing Home Health Care Hospice Care Immunizations for Travel Infertility Treatment Inpatient Medical Facility Inpatient Room and Board Inpatient Ancillary Charges Inpatient Rehabilitation Facility Maternity Care Medical Supplies Mental Health and Chemical Dependency Hospital and Facility Services Nutritional Counseling Orthognathic Surgery Orthotic Devices Podiatry Prescription Drug Benefits Preventive Care Private Duty Nursing Professional Services Prosthetics Second Surgical Opinion Skilled Nursing Facility Surgery and Surgical Services (Other) Temporomandibular Joint Dysfunction (TMJ) Therapy services Transplantation services Urgent care center 11 What to Ask About Health Benefits and Why What to Ask How important is controlling health benefit costs for your organization? What health plan(s) do you offer to your employees/spouses? What percent of employees are enrolled in each plan? What is the average annual premium/cost for each plan option? How are each of the plan options funded? (self-insured status) Is each plan contributory? Amount? What is the growth rate for each plan for each of the previous three years? Have you considered a premium discount incentive? Why? To help determine the program model and the extent of HCM. To determine integration potential and evaluation potential. To refine integration potential and evaluation potential. To understand the relative use of each plan by the population. To understand the employer s economic incentive. To explore incentive possibilities. To benchmark for program effect and for evaluation of program ROI. To help incentive planning process and possible links. 12 6

7 Additional Health Benefit Terms (Pre-Reform) Plan anniversary date PPO, HMO, CDHP Plan tiers ERISA TPA Loss ratio Open enrollment FSA HRA & HSA COBRA HIPAA (privacy) HIPAA (incentive) 13 Additional Health Benefit Terms (Post-Reform) No lifetime or annual limits No pre-existing condition limitations Accountable Care Organization (ACO) American Health Benefit Exchanges (AHBE) Qualified Health Plans (QHP) Essential Health Benefit Requirements (EHBR) National Prevention Council (NPC) Annual Wellness Visit (AWV) Independent Medicare Advisory Board (IMAB) 14 7

8 Summary of Key Points The majority of employees (70%+) receive their health benefit coverage through their employer. The costs of health benefit coverage have generally been increasing faster than any other labor cost. High rates of increase in health costs have generally prompted more employer interest in wellness. Health benefit coverage always follows some basic patterns and approaches. You will probably need to find a content expert in the health benefits area. There are a variety of potential linkages and connections between wellness and health benefits. 15 Q & A Session How much do I really need to know about health benefits? What are some good resources for me to learn about health benefits? What factors are likely to affect health benefit costs? Should our wellness program address consumer health issues? Why do health insurers generally withhold claims data? What insights can claims data provide for wellness programs? Why are health plan coverage details so different? Why do you think health plan costs will continue to go up? Are employers simplifying their health plans? In a big company who works with the health plans? In a small company who works with the health plans? How will small employers likely get the benefits of wellness? 16 8

9 Download the Attachments Now.. Attachments: Chapman, L., A History of U.S. Health Benefits and a Glossary of Key Terms, Chapman Institute, 2010, p. 11, BLS Health Benefit Summary, Deloitte 2009 Survey of Health Care Consumers: Key Findings, Strategic Implications, p. 18, and a PDF copy of the slides for this module. 17 9