Volume Fifteen, Issue Four June 2012

Transcription

1 Volume Fifteen, Issue Four June 2012 In This Issue Health Plan Trends In this fourth issue of the McGraw Wentworth Benefit Advisor for 2012, we provide our annual review of health plan trends and actions employers are taking to keep health plan costs in check. The factors contributing to rising costs are complicated. Some factors can be influenced by employers, while others can t. Employers can take steps to achieve health plan budgets. This Advisor reviews local and national data on how employers are keeping health plan costs in check. We welcome your comments and suggestions regarding this issue of our technical bulletin. For more information on this Benefit Advisor, please contact your Account Manager or visit the McGraw Wentworth web site at Health plan costs have been a consistent challenge to all employers over the last decade. In 2012, increases in southeast Michigan cooled to 6% after employers made plan changes. This is encouraging news. The lower increases are likely due to employers diligence in increasing employee engagement and focusing on improving employees health. Most employers are also experiencing a brighter economic outlook in Unemployment in Michigan is in the single digits, and roughly equivalent to national unemployment figures for the first time in four years. The outlook for the auto industry is bright, which has a positive impact on suppliers and other local businesses. McGraw Wentworth s annual Southeast Michigan Mid-Market Group Benefits Survey shows interesting results for In addition to the 6% cost increase, southeast Michigan showed a dramatic increase in full-fledged wellness plans. These plans offer health assessments, biometric screenings and health coaching. Southeast Michigan also showed approximately a 20% increase in the prevalence of consumer-driven health plans. Employers are expecting a slightly lower raw trend for Depending on the survey, raw trend can fall anywhere between 6% and 9%. Unfortunately, those increases are still two to three times the rate of inflation. Employers need to remain diligent in controlling health plan costs, and some have been quite successful in doing so. In fact, 25% of McGraw Wentworth s 2012 survey participants experienced no cost increases after employer plan changes. As your organization makes plan decisions for 2013, be sure to keep the following key considerations in mind: Beginning in 2014, health care reform will complicate how employers review their health plans. The Supreme Court s decision on the constitutionality of the health care reform legislation is eagerly awaited and expected this month. The Court is expected to issue an opinion on the individual mandate and the expansion of Medicaid. The justices will also determine if striking down the individual mandate invalidates the law s other provisions. Continued on Page 2

2 Volume Fifteen, Issue Four June 2012, Page 2 Many employers have not yet focused on the 2014 impact of health care reform, pending the Supreme Court s review. Nevertheless, if the legislation stands after the final opinion is issued, employers must start seriously considering 2014 implications. Medicare, Medicaid and other governmental health programs should be on the employer s radar as well. Government health plans cover a substantial portion of the U.S. population. The government has instituted a number of payment reductions for physicians and hospitals under the Medicare program, all of which have been delayed several times through legislation. At some point, however, the reduction in fee schedules may be adopted. This means health care providers will have to make up the lost revenue elsewhere. Historically, they have done this by charging private payers, including insurance carriers, more for services. If it stands, health care reform will significantly expand the eligibility for Medicaid in This has the ability to substantially increase the number of individuals covered under the Medicaid program. For health care providers, the more Medicaid patients they see, the less reimbursement they will receive when treating these individuals. Health providers will need to increase revenue in other ways to account for a potential influx of Medicaid patients. The economy continues to improve in southeastern Michigan. The unemployment picture is the best it has been in several years. The auto industry is rebounding. The housing market is also improving. Hopefully, the momentum of economic improvement will continue. While cost challenges dominated four years ago, employers have been confronted by the various requirements of health care reform during the last two years. Unfortunately, neither of these challenges is going away. Employers will need to remain focused on keeping health plan costs in check in Long-term strategies, such as consumer-driven health plans and wellness plans, seem to be having a positive impact. Once the Supreme Court clarifies their opinion on health care reform, employers should move forward on determining the legislation s impact for 2014 and beyond. This Advisor evaluates the following issues related to health plan trends and cost control: Issues affecting medical care and costs Strategies used by employers to control health plan costs We will discuss the results of McGraw Wentworth s 2012 Southeast Michigan Mid-Market Group Benefits Survey as compared to a national benchmark, Mercer s 2011 National Survey of Employer-Sponsored Health Plans. Both data sources provide specific information regarding what employers are currently doing to control health plan costs. Issues Affecting Medical Care and Costs Health plan costs are a complex and sizable expense for all organizations. Although raw trend is expected to cool by one or two percentage points over the next couple of years, organizations need to take steps to maintain increases in the low single digits. Unfortunately, in the short term, health care reform adds to employers overall costs. For many organizations, benefit improvements are mandated to comply with several of the law s provisions. For example, non-grandfathered plans will incur an additional cost when they are required to offer coverage for oral contraceptives and breast feeding support and services, with no employee cost-sharing. This will be effective the first day of the first plan year on or after August 1, Health care reform includes some long-term provisions that may improve costs in the future. The development of Exchanges and the plans offered through them may compel carriers to become more innovative. For example, a carrier may develop a restricted network product to compete in the Exchange. That same product may then be offered to employer group health plans. It will take time to see how Exchanges influence employer-sponsored health coverage. Continued on Page 3

3 Volume Fifteen, Issue Four June 2012, Page 3 A number of factors may contribute to health plan costs in 2013: The economy has been slowly rebounding since late During the recession, health care utilization dipped. People could not always afford care, even with health insurance. Discretionary health care, including elective surgery, was put off by patients when cost became a concern. As the economy improves, health care utilization will likely increase, impacting projected utilization for Employee health is a top concern, especially for organizations experiencing limited turnover with an aging population. Health impacts costs in several ways: General health: Poor overall health in the U.S. is a pressing issue. A recent study from the Organization for Economic Cooperation and Development compared health care spending, supply, utilization, prices and quality in 13 industrialized countries. The U.S. spends far more on health care than any of the others surveyed. This high spending cannot be attributed to higher incomes, an older population or a greater supply or utilization of hospitals and doctors. Instead, the study findings suggest that higher spending is most likely due to higher prices, more readily accessible technology and greater obesity. Health care quality in the U.S. varies, and is not notably superior to the far less expensive systems of the other study countries. Japan has the lowest health care spending, which it achieves primarily through aggressive price regulation. Unhealthy employees directly affect your health plan, as well as the productivity and energy of your organization. In the next section, our survey points toward a dramatic increase in comprehensive wellness programs. These programs provide support for general health improvement. Challenges in seeking the right health care: The current U.S health care system is staggeringly complex. Patients faced with serious health conditions struggle to navigate the system to receive appropriate treatment. It is often assumed that more health care equals better health care. An annual study, conducted by Dartmouth, suggests that this is not the case. The focus should be on receiving the right care in the right setting, and at the right time. This is an extremely difficult goal to achieve with our fragmented approach to health care. Patient-centered medical homes, a concept that is gaining acceptance, may help to resolve this challenge. These medical homes promote the development of a strong relationship with a primary care doctor who treats the patient s health conditions and fosters overall health improvement. This doctor would help to coordinate the care a patient may need from other specialists. Health care reform also aims to develop resources that patients can use when weighing the benefits and risks of different treatment options. This information is critically important to their engagement with their health care providers. These tools will not be available for a few years, but they will certainly increase awareness of the quality and effectiveness of providers and treatment options. Lifestyle choices: Lifestyle decisions drive a significant amount of the health care needed in our country. Smoking, poor nutrition, obesity, and sedentary lifestyles are choices that are adversely Continued on Page 4

4 Volume Fifteen, Issue Four June 2012, Page 4 affecting our health. A recent article published by Reuters detailed the alarming impact of obesity alone. The obesity rate in the U.S. has tripled since 1960, and results in $190 billion in medical spending annually. A study published in the January, 2012 Journal of Health Economics reported differentials in health spending on the obese. Obese men incurred $1,152 in excess spending during a year, while obese woman accounted for an extra $3,613 a year. The study also indicated that the cost of obesity now exceeds the cost of smoking, in terms of additional medical expenditures. The lifestyle choices of your future employees may also warrant consideration. Poor eating and sedentary lifestyles are not just taking a toll on adults, but on children as well. The Department of Health and Human Services has published alarming statistics. The rate of obesity in children has tripled since Being overweight during childhood and adolescence increases the risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression and Type 2 diabetes as a youth. Type 2 diabetes is of particular concern, and has increased dramatically in children and adolescents, particularly in Native American, African American and Hispanic/ Latino populations. The hospital costs associated with childhood obesity were estimated at $127 million during (in 2001 constant U.S. dollars), up from $35 million during Employer wellness programs often focus on improving lifestyle choices. As employers extend these programs to their employees, they may want to consider focusing on families, too. Meaningful lifestyle changes can often be made when the whole family is focusing on change. Provider factors do influence health plan costs. Providers are concerned about the looming potential cuts in Medicare reimbursements. Although these have been delayed several times, they will have a real impact on revenue once they are finally instituted. In addition, it is likely that innovation driven by health care reform will affect providers. Health insurers, focused on quality and effectiveness over the last several years, are adopting strategies to drive members to providers who meet quality benchmarks. They are also likely to encourage treatments whose effectiveness has been proven. Studies support that quality and effective care results in lower cost. For example, imagine a physician who approaches a diabetes diagnosis in a more comprehensive manner. Medication is prescribed to control blood sugar, but the physician has the patient meet with the staff nutritionist, who helps to plan healthful meals for the patient. The physician also provides a pedometer and challenges the patient to walk 8,000 steps a day. The patient is given a log to record meals and physical activity. The physician schedules a monthly follow up visit to track the patient s lifestyle changes. This patient is more likely to follow the physician s recommendations and is able to keep diabetes in check. A doctor that simply provides a script is not providing comprehensive treatment. Other aspects of health care reform will encourage some providers to adhere to evidence-based protocols. Accountable Care Organizations (ACOs) were created as a cost-control measure for the Medicare program. The basic idea is that a hospital system would create an ACO, which would be paid a negotiated fee for an episode of care. If the ACO met certain quality Continued on Page 5

5 Volume Fifteen, Issue Four June 2012, Page 5 benchmarks, the care would likely cost less than the negotiated fee. In such cases, the ACO could keep the difference. However, if effective care was not delivered and complications ensued, then the ACO would be responsible for costs exceeding the negotiated fee. Thus, ACOs provide a very strong financial incentive to deliver high-quality, effective care. The health care cost control challenge is complex, with many underlying factors affecting the cost of care. It is important that employers understand these various factors, in order to make the best plan decisions for keeping costs in check. Strategies Employers Are Using to Control Health Plan Costs Employers should annually review their health plan costs and projected increases. Historically, employers have shifted costs, or increased employee contributions, to reach budgetary targets for the health plan. Cost-sharing alone, however, does not lead to longterm cost control. Survey data supports that employers, both locally and nationally, are gravitating to consumer-driven health plans and wellness as long-term cost control strategies. McGraw Wentworth s Southeast Michigan Mid-Market Group Benefits Survey reviews benchmark data every year in terms of plan design, cost, contributions and cost control strategies. Employers adopted interesting strategies to control costs, improve health and engage employees in Consumer-Driven Health Plans Consumer-driven health plans (CDHPs) increase participants outof-pocket costs, and are typically qualified plans that allow money to be deposited in a tax-favored account to help offset the increased member liability. It is assumed that if employees have a greater share in the cost of health care, then they will make more cost-effective treatment decisions. The McGraw Wentworth survey indicated that 33% of employers offered a CDHP plan in This is roughly a 20% increase from the 27% offering it in In addition, about 6% of employers offering a CDHP make that the only health plan option. This is a very aggressive strategy. Nationally, the prevalence of CDHPs at large employers increased at the highest rate since the inception of these plans. For employers with 500 or more employees, 32% offered a CDHP in This was up from 23% in CDHP designs are remarkably similar on the local and national levels. The median deductibles are $1,500 for single and $3,000 for family (i.e. two or more persons) coverage. Health Savings Accounts (HSAs) are the tax-favored account of choice. Nationally, employers tend to fund the HSA at a higher level, with 75% of large employers funding a portion of the HSA. Locally, only 56% of employers fund the HSA. Funding amounts nationally were a little more generous, with large employers funding $500 for single coverage and $1,200 for family coverage. Locally, employers also funded $500 for single coverage, but only $1,000 for family coverage. Locally, the cost of CDHP plans increased by roughly 2%, which is low when compared with HMO and PPO increases. Nationally, the CDHP increase was slightly more dramatic, at just under 6%. However, it is important to note that, nationally, CDHPs with HSAs are the lowest cost plan overall. The cost per employee per year is roughly $2,000 less than the benchmark PPO plan. CDHPs provide a viable option to control costs and increase employee involvement in the cost of health care. Employers that choose to fund a portion of the HSA have an additional cost control strategy in their arsenal. They can choose to adjust funding levels annually in response to cost increases, economic realities or business performance. CDHPs engage employees more in the actual cost of health care. The increased financial liability that these plans impose on members provides a strong incentive to spend health care dollars wisely, as well as to stay healthy in the first place. This encourages members to seek generic drugs, research their treatment options, consider costs, and actively participate in wellness and disease management initiatives. Continued on Page 6

6 Volume Fifteen, Issue Four June 2012, Page 6 Wellness Initiatives Wellness plans have remained a top strategy for the last five years, despite the economic challenges in southeast Michigan. In 2012, we saw a significant increase in the number of employers offering fullfledged wellness programs. Fullfledged wellness programs are defined as offering a health assessment, biometric screenings and health coaching. In 2011, 15% of employers offered full-fledged wellness plans. In 2012, 28% of employers offered them. Nationally, interest in wellness remains a top cost-control strategy for large employers. Mercer also indicates an increase in employers offering wellness. In 2011, 24% took advantage of add-on wellness initiatives offered through their health plan vendors. An additional 23% offered expanded wellness through a specialty vendor focused on health management services. Incentives are a critical piece of the wellness picture. Locally, our survey data supports the use of incentives to encourage participation in wellness. For the 59% of employers offering incentives, the participation rate is between 76% and 99%. The 41% of employers that do not offer incentives, however, achieve less than a 10% participation rate Single Deductible $ 500 $500 I n-network Coinsurance 80% 80% Single Out-of-Pocket Max (includes deductible) $ 2,000 $2,000 Office Visit Copay $ 25 $25 Urgent Care Copay $ 30 $30 Emergency Room Copay $ 100 $100 Rx Copays $10 generic/$30 preferred brand/$60 non-preferred brand $10 generic/$30 preferred brand/$60 non-preferred brand The incentive picture is a bit different between southeast Michigan and national organizations. Southeast Michigan provides substantially greater incentives for wellness. The average annual cash incentive is $185. If the incentive is a reduction in premium, the dollar amounts are even higher, averaging $329 per year for single coverage and $687 for family coverage. Nationally, the average incentive is $221 per year, whether cash or a premium reduction. Wellnessdriven plan designs are popular in southeast Michigan, with 29% of HMO plans and 6% of PPO plans reporting a wellness-driven plan design. These plans offer both standard and enhanced levels of benefits, and members can maintain the enhanced level by either participating in certain wellness activities or by achieving specific health goals. The requirements to achieve the enhanced level of benefits vary by carrier, with many plans moving to outcomes-based arrangements. This means that, to qualify for the enhanced benefits, a member needs to truly achieve specific health targets and not just participate in health improvement activities. Of the wellness-driven HMO plans, 52% require the achievement of a health factor to qualify for the enhanced level of benefits. Again, this is largely due to product design. Tobacco surcharges continue to be of interest to employers, as they provide a strong incentive for employees to quit smoking. However, few have actually adopted this feature. Locally, only 10% of employers charge a tobacco surcharge, while nationally 12% of employers do this. Only 6% of employers assessing a tobacco surcharge actually screen employees for nicotine use. Some employers are moving to wellness surcharges. This type of arrangement requires the development of an initial wellness score, based on information from the health assessment and biometric screenings. Each year, goals are set to encourage the improvement of the health score. Because tobacco use has a significant impact on the health score, employers taking this approach would not adopt a tobacco surcharge, as this would doubly penalize smokers. The McGraw Wentworth survey indicates that some employers are still facing barriers to implementing wellness. The primary barrier is the lack of budget. Continued on Page 7

7 Volume Fifteen, Issue Four June 2012, Page 7 PPO HMO CDHP $ Amount % of Premium $ Amount % of Premium $ Amount % of Premium 2012 Single $ % $ 87 21% $ 64 17% 2011 Single $ % $ 77 20% $ 58 17% 2012 Family $ % $ % $ % 2011 Family $ % $ % $ % Wellness strategies will continue to be adopted by employers in an effort to control long-term health care costs. Improving employees health and lifestyle behaviors positively impacts both the health plan and the productivity and energy of an organization. Plan Design Southeast Michigan showed very little change in median PPO plan design. There was no change in any key plan provisions between 2011 and 2012 (see table on bottom of page 6). The McGraw Wentworth survey showed average deductibles increasing substantially in 2011 and Each year showed the average deductible increasing by approximately $100. This means some employers have moved beyond the $500 deductible to even higher amounts. From a national perspective, the median PPO plan is remarkably similar to southeast Michigan s median plan. National plans, however, have a slightly lower office visit copay ($20) and slightly lower prescription drug copays ($10/ $30/$50). The median HMO plan in southeast Michigan showed major plan design changes in 2012, and differs from the typical national plan design in several ways: In 2012, 50% of local HMO plans offered 90% coverage after the employee paid any applicable deductibles and copays. This means that the median HMO plan no longer has 100% coinsurance. (Mercer does not report coinsurance for HMO plans.) A deductible applies to 50% of local HMO plans, with the median deductibles being $500 for single coverage and $1,000 for family coverage. In addition, 20% of plans report having an inpatient hospital deductible. Nationally, 57% of HMO plans have adopted inpatient hospital deductibles. For both southeast Michigan and nationally, the median inpatient hospital deductible is $250. Office visit copays are a common feature of HMO plans. Both locally and nationally, the office visit copay is generally $20. Split copays are a plan design feature that applies one copay for primary care visits and a higher copay for specialist visits. Approximately 46% of national HMO plans have a higher copay for specialist visits, with the median specialist copay being $35. Only 37% of HMO plans in southeast Michigan have the split copay design; the median specialist copay is also $35. Both locally and nationally, HMO plans include an emergency room copay of $100. The HMO market in southeast Michigan is vastly different from the national market. Nationally, HMO plans remain the most expensive plan option, but they are one of the most affordable plan options in southeast Michigan. They continue to be a cost-effective choice locally because of strong competition and innovative plan designs. Contribution Strategies Employee contribution data was interesting in both the local and national survey data. For some plans, the employee contributions remained relatively flat year over year. Other plans, however, saw increases to contributions. Continued on Page 8

8 Volume Fifteen, Issue Four June 2012, Page 8 Employee contributions in southeast Michigan for 2011 and 2012, in monthly dollars and as a percent of premium, are as shown in the table at the top of page 7. As you can see, there was very little change to the PPO contribution amounts in terms of dollars and percent of premium. However, there were contribution increases for both HMO plans and CDHP plans. Many employers considered implementing per-dependent contributions, but only 4% actually adopted this strategy. A number of factors should be considered before adopting a per-dependent contribution structure: This contribution structure does not match the carrier s rate tiers. It is important to review an impact analysis of the proposed per-dependent contributions compared with the current contributions structure. This review often indicates that some individuals would experience drastic increases in cost. Employers must confirm that their HRIS and payroll systems can accommodate the complexities of a per-dependent contribution structure. Employers should review their contributions structure for In 2014, the affordability test will be based on the cost for single coverage only. In Michigan, employers tend to fund a greater portion of the cost for family coverage. Thus, your organization may have some flexibility with regard to family contributions, which will not impact your 2014 decisions. Prescription Drugs The prescription drug landscape has changed dramatically over the last decade. In 2002, prescription drug trend was between 18% and 22%. For the last two years, prescription drug trend was less than the overall health plan trend. In 2002, a successful employer was achieving a 50% generic utilization rate. Today, an employer that is extremely focused on generics may have a generic utilization rate around 90%. Prescription drug trend is positively impacted by the significant number of blockbuster medications losing patent protection. For example, new generic versions of Lipitor should be available this month, which will even further reduce drug spending. Employers are partially driving cost-effective use through copay structures. Nationally, three-tier prescription drug copays are the predominant plan design, with 72% of plans reporting a three-tier structure. Locally, only 60% of PPO plans have a three-tier structure. The copays themselves have not changed significantly in the last three years. Nationally, the median prescription drug plan has a $10 copay for generics, a $30 copay for formulary brands and a $50 copay for non-formulary brands. Locally, the median prescription drug plan has slightly higher copays, with a $10 copay for generics, a $30 copay for formulary brands and a $60 copay for non-formulary brands. Medical management programs, such as step therapy and prior authorization, are also driving costeffective utilization. Employers can boost generic utilization by adopting a mandatory generic provision, in which the plan will only pay for a generic medication (if a generic is available). If the doctor requires, or the patient requests, the brand-name drug instead, then the member will be required to pay the difference in cost. These medical management programs are fairly common in Michigan: 48% of plans require prior authorization or step therapy 35% of plans include mandatory generic provisions Several local carriers are expanding drug programs to include fourth and fifth tiers. New options may be available in the future to help push more cost-effective use. The high cost of specialty medications remains a concern. Specialty medications are often quite expensive, and require different handling or administration (for example, injectable drugs may need refrigeration). These medications are used to treat serious and chronic health conditions, including cancer, multiple sclerosis and rheumatoid arthritis. Generally, utilization rates for these medications are low, but their cost is high. Utilization rates are expected to increase over time. Continued on Page 9

9 Volume Fifteen, Issue Four June 2012, Page 9 The Pharmaceutical Strategies Group reported some alarming statistics in 2012: Specialty drugs account for 15% to 25% of total drug spending Specialty drug spending is expected to increase by 15% to 20% annually By 2030, specialty drugs are projected to account for as much as 44% of total drug spending Locally, we saw a large increase in the use of a fourth tier. This tier is generally added to address specialty medications. In 2012, 31% of plans reported a fourth tier, up from 19% in Employers have been aggressive with medical management programs and incentives to drive costeffective use. This diligence has contributed to cost control. In fact, employers are using these programs instead of continuously raising copays. As a result, prescription drug copays, both locally and nationally, have changed very little in the last three years. Eligibility Strategies Employers rely on a variety of eligibility strategies to check health plan costs. Locally, employers generally use two strategies to limit spousal enrollment. Fifteen percent of employers have implemented the more aggressive spousal force-out. With this provision, if a spouse has coverage available through his/her employer, then the spouse is not eligible for coverage under your health plan. Spousal force-outs are not popular with employees, because they can force the family to split the household for health insurance purposes with different plans, deductibles and out-of-pocket maximums. The other way to limit spousal enrollment is through a spousal coverage surcharge, used by 15% of employers. With this strategy, if a working spouse is eligible for coverage through his/her own employer, then the employee would be charged an extra premium to cover the spouse on his/her plan. The median monthly surcharge amount is $100 in These strategies are not as popular nationally. Only 7% of large national employers have a spousal force-out, and 7% charge a spousal surcharge. The 2014 health care reform mandates may prompt employers to make changes to eligibility. The play or pay rules that go into effect will require employers to offer coverage to fulltime employers or pay a penalty. For the first time, the federal government will define full-time as working 30 or more hours per week. More details will be needed to calculate the impact of this requirement on employers. Guidance is expected on how to define fulltime and how to measure hours worked. Employers should continue to carefully manage eligibility to keep health plan costs in check. Concluding Thoughts The McGraw Wentworth Southeast Michigan Mid-Market Group Benefits Survey showed health plan costs increasing by 6% after plan changes in Last year, health plan costs increased at 8% after plan changes. Interestingly, 25% of survey respondents experienced no change to costs, or had a reduction in costs, in Our survey results showed a clear trend of employers embracing CDHPs and wellness as long-term cost control strategies. Certainly, it appears that the early adopters of CDHPs and wellness are reaping benefits from employing these strategies. We expect this trend to continue over the next few years. Employers can manage health plan costs, but it is critical to begin the planning process early. To the extent that the changes implemented encourage employees to adopt healthy lifestyles or to make costeffective treatment decisions, your plan will be more capable of controlling increased costs over time. It is important to educate employees, no matter what changes are made to your plan. Employees need to know that they share responsibility with the employer for keeping costs in check, because health care spending is a sizable expense for everyone! If you have any questions about health plan trends, please contact your McGraw Wentworth Account Director. MW

10 Volume Fifteen, Issue Four June 2012, Page 10 Copyright McGraw Wentworth, Inc. Our publications are written and produced by McGraw Wentworth staff and are intended to inform our clients and friends on general information relating to employee benefit plans and related topics. They are based on general information at the time they are prepared. They should not be relied upon to provide either legal or tax advice. Before making a decision on whether or not to implement or participate in implementing any welfare, pension benefit, or other program, employers and others must consult with their benefits, tax and/or legal advisor for advice that is appropriate to their specific circumstances. This information cannot be used by any taxpayer to avoid tax penalties West Big Beaver Road, Suite 200 Troy, MI Telephone: Fax: McGraw Wentworth, Inc. 250 Monroe Ave. NW, Suite 400 Grand Rapids, MI Telephone: Fax: