3.Presentation Review of Options by Topic Hear how Manitowoc School District s self-funded health plan is maintained

Transcription

1 Self-funding health Benefits (Part 2) WASBO Accounting Conference Ken Mischler, CPA, Manitowoc School District Linda Mont, RHU, Key Benefit Concepts, LLC 2.Self-Funding Health Benefits Not a simple topic Requires much consideration Different circumstances for each group Consider the options in light of your District 3.Presentation Review of Options by Topic Hear how Manitowoc School District s self-funded health plan is maintained 4.Agenda Part 1: Overview & identification of basic elements What s in the Numbers? Part 2: Goals/Objectives: Plan Design and Services Part 3: Provider Network, specialty provider services & Prescription Drugs 5.Goals/Objectives? What do you expect to accomplish by self-funding? Design the plan to meet the determined goals Measure and monitor to assure the plan is meeting the goals 6.Manitowoc Schools District s determined goals and objectives to self-fund Key Benefit Concepts, LLC 1

2 7.Self-Insured Administration Administration Costs Include Administration Costs - claims processing claims processing Utilization review and disease/care management review and disease/care management Data Maintenance & Reporting& Reporting Large Case Management Underwriting Services Provider Network Access Wellness? Stop-Loss Premium 8.Types of Administrators Insurance Carrier Based Independent Third Party Administrators Insurance Trusts Self-Administration 9.Manitowoc Schools Current Type of Administrator History of Administration 10.Self-Insured Administration Administration o Eligibility and Enrollment Determination of eligibility According to Plan eligibility Determined by District Determined by Administrator By District confirmed by Administrator o Enrollment Manual Electronic Updates/Adjustments Key Benefit Concepts, LLC 2

3 11.Self-Insured Administration Administration o Claims Adjudication processing claims Basis of Administration Plan Document Electronic transactions Paper claims Automatic adjudication Manual adjudication 12.Cost of Health Care Three health care factors Cost of Care Number of units of care Number of Participants 250 $$ X 10 Visits X participants 13.Self-Insured Administration Utilization Review o Precertification the preapproval process for specific treatments involving determining whether the requested service is medically necessary Most common include Nonemergency hospitalizations, Outpatient surgery Skilled nursing and rehabilitation services, Home care services and some home medical equipment. 14.Self-Insured Administration Utilization Review o Retrospective Review Review of treatments or services that have already been administered, and Review of medical files in comparison with treatment guidelines. Key Benefit Concepts, LLC 3

4 15.Manitowoc Schools Precertification: District procedures/services requiring precertification list list changed over the years or eliminated 16.Self-Insured Administration o (Large) Case Management Focus on those with catastrophic or severe illnesses Guide patients and their families Answering questions, offering support and expertise. Effective in assuring the best treatment while controlling costs Reduce escalation in Plan Costs -- and in turn stop loss coverage 17.Self-Insured Administration o Disease/Care Management Cardiac Conditions Asthma Diabetes Depression/Stress Others 18.Chronic Conditions Key Benefit Concepts, LLC 4

5 19.Manitowoc Schools o How does the District provide: Utilization Review Large/Case Management Disease Management o Are the services provided by the claims administrator, outside service, etc.? If outside, how does the coordination work with the TPA? o How has the District monitored and measure the effectiveness of these services? 20.Self-Insured Administration o ACA Compliance/Coordination/Administration Minimum Value Actuarial Valuation Transitional Reinsurance Fee Patient-Centered Outcomes Research Institute Fee (PCORI) Employer Shared Responsibility Payment (Pay or Play) Information Reporting on Health Coverage by Employers Other 21.Manitowoc Schools How much work has it been to administer the ACA fees/taxes? How much assistance does the District receive from the Administrator? Where does the District get the most support in preparing for and reporting the ACA fees/taxes? 22.Plan Administration Other Services Hospital bill audits Subrogation and Right of Recovery 23.Manitowoc Schools Comments on Subrogation/Right of Recovery Hospital bill audits Other ancillary services for the plan? Key Benefit Concepts, LLC 5

6 24.Self-Insured Administration Wellness Engaging Employees Educational Activities Measurement Long-term benefits o Plan Participants o Plan o District 25.Manitowoc Schools o Wellness Services and: The part that yor administrator plays, if any Employee engagement The impact on: Employee health/well-being Plan costs Plan health status (did you curb the # with health conditions or severity or number of conditions?) 26.Plan Design Beyond the Deductible/Coinsurance/ OOP What benefits are covered? How they are covered? How they are administered? For Example: Chiropractic Excludes maintenance How is that administered? Monitored? Third Party Liability Pay and Pursue? Pursue then Pay? Key Benefit Concepts, LLC 6

7 27.Plan Design Documentation Thorough Plan Document User-Friendly benefit booklet How do you handle updates/changes? Administration Proper administration tools Customer Service Responses Appeals Process By Administrator By District What levels 28.Manitowoc Schools How the District s document was created, updated How the Administrator assures administration according to the determined plan How District determine plan changes and how the changes are communicated and documented. Other items? 29.Manitowoc Schools Final info on Plan goals and objectives Specifics on how you designed plan to meet goals Your measurements to assure meeting goals 30.Goals/Objectives Revisit: What do you expect to accomplish by self-funding? Design the plan to meet the determined goals Measure and monitor to assure the plan is meeting the goals 31.Questions/Discussion Thank You 32.Next Session Provider Network, specialty provider services & Prescription Drugs Thank you Key Benefit Concepts, LLC 7