Employer Benefit Underwriters, Inc. Administrative Guide For Stop Loss Insurance

Transcription

1 Employer Benefit Underwriters, Inc. Administrative Guide For Stop Loss Insurance 1

2 Welcome to Employer Benefit Underwriters, Inc. Thank you for allowing us the opportunity to serve you and our mutual clients. The purpose of this guide is to familiarize you with information pertaining to the Stop-Loss coverage provided to our mutual client. It is important as an Administrator of a Self-Funded plan that you become familiar with the provisions as to not jeopardize the eligibility of this coverage. Let this Administrative Guide serve to explain your responsibilities as an Administrator of the EBU Stop-Loss coverage. Nothing contained within this Administrative Guide changes the terms of the Medical Stop Loss Policy / Treaty. The language contained within the Medical Stop Loss Policy / Treaty will take precedence if there is any conflict between the Administrative Guide and the Medical Stop Loss Policy / Treaty. Please contact us should you any further questions or require additional explanation. CONTACT INFORMATION EBU Headquarters 100 LaCosta Lane Suite 120 Daytona Beach, FL Phone: (386) Toll-Free: (888) 500-EBUI (3284) Daytona Beach Fax: (386) EBU Chicago 524 West State Street, Suite D Geneva, IL Phone: (386) Toll-Free: (888) 500-EBUI (3284) Geneva Fax: (630) Please send all mail, premiums, claims and correspondence to EBU Headquarters DEPARTMENT CONTACTS Underwriting Office Manager Policy & Licensing Brian Murphy Laurie Billups Angelica Colombi (386) x 305 (386) x 307 (386) x 306 bamurphy@ebu-inc.com laurie@ebu-inc.com acolombi@ebu-inc.com Claims National Sales Business Development Ann Dobranic Jacqueline Easley Tina Willenborg (386) x 303 (386) x x 414 adobranic@ebu-inc.com jacqueline@ebu-inc.com tina@ebu-inc.com 2

3 RESPONSIBILITIES OF AN APPROVED THIRD PARTY ADMINISTRATOR (TPA) EBU requires a completed TPA Questionnaire and an EBU TPA Checklist with required attachments. If you have a TPA Questionnaire completed within 2 years on file, you may submit that along with the EBU TPA Checklist and required attachments for review and approval. It is your responsibility as an Approved Administrator / Appointed Agent to: Keep accurate records available to be reviewed by EBU if requested Provide payment of premium by the 1 st of each month Provide Monthly Aggregate Reports by the 20 th of each month following the month in which the premium is due Submit all items listed in Sold Case Submission in a timely manner so the policy can be issued within 90 days of the group s effective date, as required by the carrier. Note: claims cannot be processed for payment until the policy requirements have been satisfied, the policy has been issued and signed signature pages have been received by EBU) Maintain and provide proof of current Agent and TPA Licenses as required by the carrier and applicable laws Maintain and provide proof of Fidelity and Errors & Omissions Coverage Notify EBU if claimant is reasonably expected to reach 50% of specific deductible Notify EBU immediately of any lawsuits or insurance department complaints that may affect EBU Provide notice of an amendment to a client s Plan Document prior to the effective date of the amendment (Note: EBU reserves the right to adjust rates and factors based on any material change to the benefit plan). Immediately notify EBU when aware of a Potential Specific Claim, see page 7 Click this link to complete the TPA Forms online Questions regarding TPA Approval, Licensing or Policy Issuance, please contact Angelica Colombi at acolombi@ebu-inc.com RESPONSIBILITIES OF A TPA 3

4 STOP LOSS CARRIERS As a leading National Managing General Underwriter (MGU), EBU offers Medical Stop Loss Reinsurance through the following company: Fidelity Security Life Insurance Company A.M. Best Rating: A (Excellent) STOP LOSS PRODUCTS, COVERAGE & CONTRACTS Specific Stop Loss Insurance provides financial protection for self-insured employers from large claims that occur for any one covered individual, it is designed to protect the plan sponsor from large individual claims. This dollar amount is called a specific deductible. Specific Deductibles are available from $15,000 to $1 Million per individual, once this deductible is satisfied by an individual; the insurance company reimburses to the plan sponsor the amount over the deducible. Coverage: Medical or Medical and Rx Specific Deductibles from: $15,000 - $1 Million Unlimited Maximum: Medical or Medical and Rx Specific Advance Reimbursement Specific Premium is based on the following factors: Age of Group, Gender, Zip Codes, Single / Family Coverage, Contract Type, Industry and Schedule of Benefits. Aggregate Stop Loss Insurance limits the plan sponsors exposure to a maximum annual claim liability for all eligible claims submitted. This dollar amount is called an attachment point. The attachment point will move up or down according to plan participation during the year, but will never be lower than the minimum attachment point. The insurance company will reimburse the plan sponsor at the end of the plan year for the total amount of claims in excess of the attachment point, minus any specific reimbursements. Coverage: Medical or Medical and Rx, Dental and/or Vision (aggregate only) Aggregate Limit: $1,000,000 ($2,000,000 and $5,000,000 available) Standard Attachment Point: 125% of expected claims Aggregate Attachment Factors are calculated on the actual experience for the group and the plan of benefits requested. Two years of month to month paid claims experience is needed, as well as the monthly enrollments. Other Available Options: Aggregating Specific Deductible Terminal Liability Reference Based Pricing No New Laser on Renewal Contract Basis: 12/12, 12/15, 12/18, 15/12, 18/12, 24/12 Monthly Aggregate Accommodation Transplant Coverage Level Funding Innovative options please contact Sales for more information on our innovative options to assist clients transitioning from Fully-Insured to Self-Funding. STOP LOSS 4

5 UNDERWRITING GUIDELINES Table 2 EBU s Underwriting Guidelines Fidelity Security Life Insurance Company Minimum Group Size 26 employees Minimum Specific Deductible $20k States Available All States Aggregating Specific Deducible (Option Available) Specific Advance Funding (Option Available) Yes Yes Monthly Aggregate Accommodation (Option Available) Yes Aggregate Terminal Liability (Option Available) Yes Minimum % Participation 70% Reference Based Pricing Level-Funded Option When requesting a quote, please send the following to info@ebu-inc.com: Yes No Traditional Medical Stop Loss Proposal General Effective Date Company Name, Location Industry Type / SIC Code Number of Employees, Effective Date Specific Deductibles Contract Basis for Specific / Specific and Aggregate Coverages Current / Renewal Rates Current / Proposed PPO Network Current TPA / Proposed TPA Schedule of Benefits Deductible, Out of Pocket Maximums, Coinsurance and Copays Rx Benefits Out of Network Benefits Reference Based Pricing (If applicable and TPA Approved) % Medicare to be quoted for Inpatient, Outpatient, and Physician Services subject to the wrap network discount? Census in Excel Date of Birth, Gender, Single / Family Coverage, Zip Codes, Plan Choice (if offering multiple), Retiree and COBRA Participants Shock Claims Experience Experience Year, Amount of Claim, Name, Diagnosis, Treatment Plan and Current Status Aggregate Quote Prior 2 years Paid Claims (3 years is preferred) and Corresponding Enrollment Figures Upon sale of proposal, EBU requires disclosure of disabled and COBRA participants, potential large claims in excess of 50% of deductible (or reasonably expected to reach 50% based on diagnosis and/or treatment plan). EBU will adhere to State Insurance Regulation Minimums regarding employer/risk size restrictions. Please consult Sales or Underwriting for additional information. UNDERWRITING 5

6 For TPA Reference Based Pricing (RBP) Program approval please send the following information to Sample Plan Document List containing number of Covered Employees / State Claims Administrator Program Name Program Implementation Date Number of clients who implemented the program What, if any, wrap network used? What services are subject to reference based pricing (e.g., inpatient, outpatient, physician)? Does this vary for each client or is it standardized for all? How is balance billing handled? Click this link to complete the RBP Info Form online Please note outside vendors used to assist with re-pricing, plan language or balance billing Industries Currently Declined: Casinos Employee Leasing Firms Hospital Consortiums Associations Multiple Employer Welfare Associations Long Haul Trucking Indian Tribes Professional Employee Organizations Updates are made periodically to Industries Currently Declined. Please contact us if you have questions about specific SIC Codes that may or may not fall under one of the above listed categories. Questions regarding Underwriting, please contact Brian Murphy at bamurphy@ebu-inc.com or Sales at sales@ebu-inc.com UNDERWRITING 6

7 SOLD CASE SUBMISSIONS Disclosure of disabled and COBRA participants, potentially large claims and claims in excess of 50% of deductible (or reasonably expected to reach 50% based on diagnosis and/or prognosis) is required by EBU upon sale. Therefore, for a proposal to be considered sold, prompt submission of these documents within the listed time frames will expedite Stop Loss Policy issuance: Upon Sale 10 Days 30 Days 60 Days Carrier Disclosure Statement Completed Stop Loss Application Deposit Premium TPA Questionnaire TPA Checklist w/ Attachments Claims Experience (as of Effective Date) Final Enrollment Census (as of Effective Date) Qualifications Requested on Quote Plan Document Please Note: Our Carriers require that we issue policies within 90 days of the effective date of coverage. Stop Loss Policy will not be issued until receipt of all above items, nor can claims be processed and paid until the Stop Loss Policy has been issued, and the appropriate signature pages have been signed, witnessed, and then returned to and received by our office. PREMIUM SUBMISSION The binder premium is due no later than the 1st day of the Contract Period. Subsequent monthly premiums and reports with counts by tier are due the 1 st day of each month. The contract provides for a 31-day grace period. If the premium payment is not received by the end of the grace period, the policy can be considered lapsed retroactive to the last day of the month for which premium has been paid. Reinstatement of the lapsed policy will be considered only once, and at the sole discretion of the issuing Carrier. SOLD CASE SUBMISSIONS 2018 Employer Benefits Underwriters, Inc. 7

8 CLAIMS MONTHLY PAID CLAIMS REPORTS The Monthly Paid Aggregate Report Form must be submitted by the 20 th of the following month for which claims are being reported (August claims should be reported by September 20 th ). Report only claims which are covered under the policy and remember to subtract void checks, refunds, ineligible claims, and specific reimbursements. UTILIZATION REVIEW Click this link to complete the claims forms online Utilization Review (also known as pre-certification) is defined as the procedure by which the company provides certification for those admissions that require an in-patient confinement based on medical necessity. Concurrent Review monitors the continued need for an in-patient confinement in an acute care setting. Retrospective Review process of obtaining information from providers and facilities in cases where the care has already been rendered STOP LOSS CLAIMS ADVANCE NOTICE OF CATASTROPHIC CLAIMS / NOTICE OF CLAIMS REACHING 50% OF THE DEDUCTIBLE EBU needs to be notified and involved at the beginning of the catastrophic claim. We consider notification of claims that are at 50% of retention and potentially catastrophic claims to be an integral function of the TPA. All quotes issued require Utilization review and Large Case Management. Please notify EBU when the claim reaches 50% of the Specific Deductible, even if you have provided EBU with an advance notice of a potential claim. Please provide an Advance Notice of a Catastrophic Claim at the earliest indication of one of the following conditions related to the ICD-10 Trigger Diagnosis List: Accidents: Head / Spinal Cord Injury, Traumatic Brain / Head Injury, Severe Burns, Internal Injuries, Multiple Crushing Injuries and/or Fractures Amputations: Major extremities Blood Disorders: Sickle Cell Anemia, Aplastic Anemia, Hemophilia, Thrombocytopenia, AIDS / AIDS Related Complex/ HIV / Disorders of the Immune System Cancer: malignancy of solid organ, blood or lymphatic system Cerebral Vascular Accidents Congenital Defects: Brain, Nervous System, Spinal Cord, Chromosomal / Genetic abnormality, Cystic Fybrosis, Cerebral Palsy Diabetes Mellitus: with complications or likelihood of claims > $50,000 Hospital Stays: > 7 days, multiple admissions within 12 month period Infectious Diseases: Tuberculosis, Septicemia, Bacterial Meningitis, Osteomyelitis IV Therapy: Enzyme Replacement, Antibiotic Therapy, TPN/TPA Kidney Failure / End Stage Renal Disease: Dialysis Newborn with Complications: Prematurity, Birth Trauma, Respiratory distress / disorders, Congenital Anomalies CLAIMS 8

9 Neurological Disorders: Amyotrophic Lateral Sclerosis (ALS), Muscular or Cerebral Dystrophy, Stroke, Multiple Sclerosis (MS), Obstetrical Complications: High Risk Pregnancy, Expected Multiple Births Psychiatric: hospital confinement or otherwise likelihood of claims expected > $50,000 Transplants: Major Organs, Bone Marrow, Stem Cell, Complications thereof / post- transplant patients Other: Artificial Joint or Cardiac Implant Surgery, Growth Hormone Therapy, Mechanical Assistance Dependency (Apnea Monitor, Ventilator, Ventricular Assistance Device, other requiring medical assistance to sustain life), patients in Medical Case Management, Patients requiring Skilled Nursing Facilities, Home Health Care, Hospice, Daily Private Nursing; Fibromyalgia and other Fatigue / Stress Conditions, Chronic Pain Management; Interim Hospital Billings; Intensive levels of Home Health Care Supplies / Service, Severe Respiratory Disorders (COPD, Emphysema, Pneumonia, Pulmonary Fibrosis), Crohn s Disease (Regional Enteritis), Cellulitis / non-healing surgical wound, Congestive Heart Failure or Cardiomyopathy, Quadriplegia, Liver Disease, Coma, Specialty Drugs with likelihood of claims > $50,000 FILING A SPECIFIC CLAIM Please complete the following EBU Form and submit to our Claims Department: Request for Specific Reimbursement Form Provide the following additional information: TPA s Comprehensive Claim Detail Report or EOB s Copy of actual enrollment card reflecting the initial effective/hire date, enrolled dependents and plan selection Eligibility documents for enrollment and plan changes, employee work status / continuation of coverage, other coverage within 12 months and COB rules of the plan Comprehensive Paid Claim Report including ICD 10, CPT, UB04 Revenue and HCPCS codes, Check dates, numbers and amounts, provider and payee information Copies of all supporting bills and EOB s to be considered (when a comprehensive paid claim report is not available) Supporting documentation for negotiated discounts, hospital bill reviews, adjusted claims or fees HCFA and UB04 bills in excess of $20,000 (when submission includes a comprehensive paid claim report) Itemized bills > $50,000 Copies of completed Claim Worksheet(s) Bills for applied deductible as of the policy effective date Proof of applied deductible and out-of-pocket prior to policy effective date Proof of funding the Specific Deductible, Laser Deductible or Aggregating Specific Deductible Copies of claim drafts showing payment(s) issued Pre-Certification documentation Patient claim form and attending physician s statement(s) Copies of all investigative correspondence (LCM, Utilization Review, Certificates of Credible Coverage, Physician s Orders and Treatment Plans) COBRA election form and proof of premium payment (if applicable) Signed subrogation letter and police report (when applicable) List of Claims held for Advance Funding (when applicable) CLAIMS 9

10 Specific claims will be reimbursed according to the Stop Loss Contract according to the Plan Document benefits and provisions, payment accuracy, investigative results and claimant eligibility. If an investigation was conducted we will require a copy of all correspondence and responses. Claimant eligibility will be based on the provisions in the Plan Document, underwriting disclosure, COBRA participation and employment status. On claims that involve a third party we will require accident details, police report, other insurance information, a signed subrogation agreement, and the name and phone number of the claimant s attorney. This information will be forwarded to the carrier for further review. HOSPITAL BILLS In an endeavor to achieve greater claims savings we request that alternative cost control methods be used in lieu of hospital audits. It is preferred that a discount be negotiated with the facilities. This negotiation can be performed by a qualified member of your staff, or by an outside vendor. If you are unable to negotiate with the provider, if the bill is considered immoderate or a substantial savings cannot be realized from a discount, we request that the bill be sent to a professional bill review company. Our Claims Department can provide the names of firms that provide line item analysis and repricing. It is expected that all hospital bills exceeding $50,000 or that appear to be excessive, have some cost savings procedure implemented. It is recommended that 10% of the bill be pended until an audit can be arranged and remain pended until the audit results have been provided. All hospital bills should be analyzed for excessiveness considering the diagnosis, length of stay and the treatment rendered. FILING AN AGGREGATE CLAIM Please complete the following EBU Form and submit to our Claims Department: Aggregate Reimbursement Request Provide the following additional information: Detailed Paid Claims Reports, Medical and Rx (Dental and Vision if applicable) Detailed Census listing Employees and Dependent dates of birth, original effective dates, change of status dates and termination dates Eligibility documents for enrollment and plan changes, employee work status / continuation of coverage, other coverage within 12 months and COB rules of the plan COBRA Census including election forms and premium proof Ineligible Claims Summary (out-of-contract or extra-contractual claims) Benefit Code Summary (including vendor fees) Voids, Refunds, Overpayments & Stale-dated checks (received, posted and pending) Specific Claims Summary Subrogation claims detail and support Rx Rebates Annual Check Register Final Bank Statement Premium Payments Summary Prior Monthly Reimbursements CLAIMS 10

11 Upon receipt of the claim and supporting documentation, a review will be made by our Claims Department to determine if an on-site audit will be necessary. If one is required, you will be contacted regarding the scheduling of the audit. At that time, you will be provided with a list of claims to be audited and any additional materials that will be necessary. We will make every attempt to schedule onsite audits within thirty days of receipt of the Aggregate Reimbursement Request. FILING A MONTHLY PAID AGGREGATE CLAIM Please complete the following EBU Form and submit to our Claims Department: Monthly Paid Aggregate (MPA) Reimbursement Request form Provide the following additional information: Aggregate Report Detailed Claims Reports subtotaled by claimant (Medical and Rx, Dental and Vision if applicable) Participant coverage census report showing original effective dates, termination dates, COBRA participants, dependent names and dates of birth Check register including any voids and refunds Bank Statement showing monthly deposit based on enrollment Coverage analysis or benefit code summary showing total claim dollars paid by benefit code Rx detail report and Rx Payment sent to the PBM (RX Rebates paid to the group or TPA are needed for the year-end aggregate claim) Specific Claims Analysis listing members at 50% of the Specific Retention and those at or greater than 100% of the Specific Retention Accounting breakdown of Specific Premiums, Aggregate Premiums, Claim Liability (attachment point dollars) and Laser Once an MPA claim is paid, it will be necessary to file every month until the end of the policy period or until all reimbursements have been refunded. With subsequent filings, you need only furnish Claims Paid Reports for the succeeding months. The final claim will be handled as an Aggregate Claim, please provide: Paid Claims Report for the Policy Period summarized by Claimant. An updated eligibility listing. Check registers by month for the policy period. Proof of funding of the final check register. Copies of COBRA election forms and proof of payments for all COBRA participants with claims paid including this request. EXTRA-CONTRACTUAL EXCEPTIONS Claims paid outside the provisions of the Plan Document will not be reimbursable under the Specific or Aggregate Stop Loss coverage without prior approval. Requests must be in writing, provide the Claimant and Group name, summarize the claim situation and state the out-of -plan proposal. Please include the reasoning for the action, medical necessity and cost savings to the plan. It is important to include the exact cost amounts, proposed frequency and duration of treatment. EBU will request Carrier Review and will submit the Carrier s response in writing. CLAIMS 11

12 PAYMENT EXTENSIONS Claims paid outside the payment terms of the stop loss policy will not be reimbursable under the specific or aggregate stop loss coverage without prior approval. Requests must be made in writing and dated by the end of the policy year or the run-out period. Provide the name of the claimant and the group. Furnish the exact dollar amount of the pended charge, the name of the provider and the reason the charge has been pended. Requests will be reviewed promptly and responses will be made in writing. NOTIFICATIONS OF DENIED CLAIMS Our Claims Department should be notified of claims that have been denied as a result of ineligibility or plan document provisions. We need to be notified only if the amount denied exceeds the specific deductible. Your report should include the claimant and group name, the amount denied, dates of service and the reason for the denial. CLAIMS Questions regarding Claims, please contact Ann Dobranic at adobranic@ebu-inc.com 12