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 An Overview September 11, 2015 September 11, 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. September 11, 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 September 11, 2015 Subject to Change Without Notice 3

4 WHY SELF-FUNDING WHY THE PROTECT PLANS September 11, 2015 Subject to Change Without Notice 4

5 The Fixed-Cost Self-Funded Option Self-funded plans with stop-loss coverage may look like traditional health plans Comprehensive Medical Coverage Fixed Monthly Employer Costs Protects Employers When Claims Higher Than Expected Fixed-Cost Self-Funded Traditional Fully Insured September 11, 2015 Subject to Change Without Notice 5

6 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 Fixed-Cost Self-Funded Employer Traditional Fully Insured Insurer Heads you win. Tails you don t lose. September 11, 2015 Subject to Change Without Notice 6

7 Self-Funded is Different Employers need to understand the difference between fully-insured and self-funded plans Self-funded programs regulated under federal law (ERISA) Same benefit plans may be offered in multiple states Claim fund is exempt from premium tax Excess-loss premiums are not Same plans may be offered in multiple states The employer is responsible for claim payments Makes protecting exposure with specific and aggregate excess-loss coverage (stop-loss) critical September 11, 2015 Subject to Change Without Notice 7

8 Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters September 11, 2015 Subject to Change Without Notice 8

9 The Protect Plans Advantage 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 September 11, 2015 Subject to Change Without Notice 9

10 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 September 11, 2015 Subject to Change Without Notice 10

11 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) September 11, 2015 Subject to Change Without Notice 11

12 The Protect Plans Difference Protect Plans Traditional Level Funded Plans Fixed Monthly Costs Claim Surplus Refund 100% Partial-to-100% Offer Refund Assisters SM? September 11, 2015 Subject to Change Without Notice 12

13 The Protect Plans Advantage Refund Assisters SM All level-funding and maximum funded plans offer employers the chance to earn claim surplus refunds The Protect Plans help deliver on that promise September 11, 2015 Subject to Change Without Notice 13

14 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 program Provided through Healthy Merits, Meritain Health for Life, and Disease Management administered by Meritain Health September 11, 2015 Subject to Change Without Notice 14

15 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 September 11, 2015 Subject to Change Without Notice 15

16 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 September 11, 2015 Subject to Change Without Notice 16

17 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 September 11, 2015 Subject to Change Without Notice 17

18 PLAN DESIGNS AND UNDERWRITING September 11, 2015 Subject to Change Without Notice 18

19 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 September 11, 2015 Subject to Change Without Notice 19

20 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 September 11, 2015 Subject to Change Without Notice 20

21 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 September 11, 2015 Subject to Change Without Notice 21

22 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 Aetna Takeover: Need release from Aetna prior to quoting groups currently with Aetna September 11, 2015 Subject to Change Without Notice 22

23 Underwriting: Special Consideration Aetna Takeover: Need release from Aetna prior to quoting groups currently with Aetna 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 September 11, 2015 Subject to Change Without Notice 23

24 Underwriting: Participation Participation Requirements: Group 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) September 11, 2015 Subject to Change Without Notice 24

25 Underwriting: Employer Options HMO Combination: Employers may offer an HMO alongside the Protect Plans Participation requirements apply Employees enrolling in HMO are not considered eligible employees Employee Choice: Employers may offer multiple Protect Plans September 11, 2015 Subject to Change Without Notice 25

26 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 Telephone underwriting available for enrolling groups Preferred claims information: prior two years of claims, coverage, enrollment and shock claims September 11, 2015 Subject to Change Without Notice 26

27 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 ScripWorld 45-to-60 days September 11, 2015 Subject to Change Without Notice 27

28 THE PROTECT PLAN TEAM September 11, 2015 Subject to Change Without Notice 28

29 Reliable Administration Meritain Health, an Aetna company One of the nation s largest third party administrators Handles all operational aspects including Enrollment Billing Membership services Claims Compensation September 11, 2015 Subject to Change Without Notice 29

30 A Word About ACA Reports ACA Fees are not included in monthly payments Patient-Centered Outcomes Research Institute Fees (PCORI) Transitional Reinsurance Program Fee (TRP) Meritain facilitates fee calculation and payment Employer is responsible for calculating fees September 11, 2015 Subject to Change Without Notice 30

31 Broad, Strong Networks Aetna Choice POS * II (Open Access) National coverage 8,200+ hospitals 3,000,000+ physicians and specialists ScripWorld 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 September 11, 2015 Subject to Change Without Notice 31

32 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 September 11, 2015 Subject to Change Without Notice 32

33 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 September 11, 2015 Subject to Change Without Notice 33

34 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 September 11, 2015 Subject to Change Without Notice 34

35 Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters September 11, 2015 Subject to Change Without Notice 35

36 APPENDIX: SPECIAL CONSIDERATION INDUSTRIES AND WORK FLOW September 11, 2015 Subject to Change Without Notice 36

37 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 September 11, 2015 Subject to Change Without Notice 37

38 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 September 11, 2015 Subject to Change Without Notice 38

39 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 September 11, 2015 Subject to Change Without Notice 39

40 The Protect Plans 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 September 11, 2015 Subject to Change Without Notice 40