producer Alternate funded solutions Self-funding for midsize employers For groups with 51* to 300 employees * Minimum 51 enrolled employees. blueshieldca.com
Self-funded health plans are not just for large businesses anymore. Blue Shield s self-funded arrangements for midsize employer groups allow your clients to enjoy a great combination of broad provider network access with deep discounts, as well as comprehensive medical management programs. Two financial arrangements are offered: A level funded arrangement and an Administrative Services Only (ASO) plus stop-loss insurance arrangement.* Your midsize clients can now benefit from the advantages of self-funded plans: Participate in favorable claims experience: Clients can participate in favorable claims performance while retaining high-claims risk protection. Reduced premium taxes : With self-funded plans, clients pay taxes on the stop-loss premium only, which is lower than paying premium taxes on fully insured plans. Avoid mandated benefits: Self-funded plans are not subject to state mandates. Uniform plan design: Your clients with a multi-state workforce can offer a consistent and uniform health plan to all employees because self-funded plans are not subject to state-mandated benefits. Clients should contact their accountant or tax adviser for details. Blue Shield does not offer tax advice. These two funding arrangements help manage financial risks while allowing your clients to gain more control over healthcare spending. The arrangements offer lower stop-loss insurance* levels and lower aggregate risk corridors to fit your midsize client s needs. Both options can help contain healthcare costs while providing quality coverage to employees. With these arrangements, your clients will have access to a suite of administrative services, including: enrollment and eligibility, claim adjudication and processing, provider network contracting, financial and accounting services, superior employee and employer customer service, and more. Blue Shield gives midsize clients access to two funding arrangements that help manage financial risks while allowing more control over healthcare spending. * Administrative services are provided by Blue Shield of California. Stop-loss insurance is underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 2
Level funded arrangement For clients who want predictable monthly expenditures and protection from monthly claims fluctuations, the level funded arrangement is a perfect solution. Clients have an opportunity to earn a year-end refund or credit if annual claims are lower than projected. Here s how it works: The level funded arrangement s predictable cost structure makes it easy for employers to budget because the set monthly fee covers administrative services, stop-loss insurance* premiums, and projected claims up to the maximum monthly funding amount. At the end of the plan year, if the annual claims funding amount is not depleted, any monies remaining are retained by the employer. They can be applied to the cost of the next year s level funded plan or used to fund other medical benefit programs. Level funded banking overview Client Stop-loss* January Client deposits to bank account up to aggregate funding level for Blue Shield to $100,000 administer claims Total monthly claims paid by Blue Shield on client s behalf $210,000 Blue Shield debits client account (client is only liable for claims up to monthly ($100,000) aggregate funding level) Stop-loss pays client s claims over aggregate funding level ($110,000) Client month-end account balance $0 February March Client deposits to bank account up to aggregate funding level for Blue Shield to administer claims $100,000 Total monthly claims paid by Blue Shield on client s behalf $35,000 Blue Shield debits client account (client is only liable for claims up to monthly aggregate funding level) ($35,000) Stop-loss pays client s claims over aggregate funding level $0 Client reimburses stop-loss for January aggregate overage $65,000 Remaining stop-loss balance ($45,000) Client month-end account balance $0 Client deposits to bank account up to aggregate funding level for Blue Shield to administer claims $100,000 Total monthly claims paid by Blue Shield on client s behalf $50,000 Blue Shield debits client account (client is only liable for claims up to monthly aggregate funding level) ($50,000) Stop-loss pays client s claims over aggregate funding level $0 Client reimburses stop-loss for February aggregate overage (up to the balance remaining in client account) ($45,000) Client month-end account balance $10,000 Client s beginning bank account balance (client month-end bank account balance from March) $10,000 Client deposits to bank account up to aggregate funding level for Blue Shield to administer claims $100,000 Total account balance $110,000 Total monthly claims paid by Blue Shield on client s behalf $85,000 Blue Shield debits client account (client is only liable for claims up to monthly aggregate funding level) ($85,000) Stop-loss pays client s claims over aggregate funding level $0 Client month-end account balance $25,000 The above chart is for illustrative purposes only. April If the plan terminates at the end of the policy period, the client is required to keep their bank account active for the claims run-out period (12 months); at the end of the 12-month period, any remaining funds will be distributed back to the client. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 3
ASO plus stop-loss insurance arrangement For clients who want more control over their monthly cash flow management with competitive administrative fees the ASO plus stop-loss insurance* arrangement is a good health benefits investment. Here s how it works: During the plan year, the employer s monthly payments are used to cover ASO fees and stop-loss insurance premiums. The employer is also responsible for paying all claims up to the stop-loss insurance thresholds. Blue Shield Life s stop-loss insurance minimizes your client s financial risk by providing protection against large/catastrophic claims and excessive utilization, so the client is protected from large claims. ASO plus stop-loss advance funding overview Specific stop-loss deductible - $15,000 Client Blue Shield Stop-loss* Specific covereage advance funding Plan participant has $35,000 in claims incurred/paid $35,000 Blue Shield bills client for claims paid on client s behalf $15,000 Client account debited for claim ($15,000) Stop-loss pays claims over specific deductible ($20,000) Aggregate stop-loss advance funding monthly accommodation January February Debited Debited Client Stop-loss Client Stop-loss Client monthly aggregate attachment from from incurs respon- incurs responpoint is $400,000 client s client s claim sibility claim sibility account account Blue Shield-processed claims week 1 $150,000 ($150,000) $100,000 ($100,000) Blue Shield-processed claims week 2 $150,000 ($150,000) $100,000 ($100,000) Blue Shield-processed claims week 3 $150,000 $100,000 ($50,000) $100,000 ($100,000) ($50,000) Blue Shield-processed claims week 4 $50,000 ($50,000) $60,000 ($50,000) Total funds transferred from client account ($400,000) ($360,000) Total balance from stop-loss ($100,000) Balance owed to stop-loss to reduce Blue Shield Life deficit ($40,000) The above charts are for illustrative purposes only. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 4
Benefit plan options Clients can choose from six PPO plan options and two pharmacy plans. 6 PPO plan options Blue Shield PPO 250-90/70 Blue Shield PPO 250-80/60 Blue Shield PPO 250-90/70 Value Blue Shield PPO 500-80/60 Blue Shield PPO 0/500-100/50 Blue Shield PPO 2250 (Savings Plus) These PPO plans can help reduce your clients costs through network discounts while providing their employees with comprehensive benefits, including preventive care benefits and direct access to doctors and specialists. Plus, Blue Shield PPO 2250 (Savings Plus) is a Health Savings Account* (HSA)-eligible high-deductible health plan (HDHP), which can help put participants more in charge of their own healthcare spending. When employees select an HDHP, they can open an HSA to pay for qualified medical expenses with tax-advantage dollars. These plans empower participants to achieve their health and wellness goals and provide: Competitive contracts and rates with one of the largest PPO provider networks in California. Your clients healthcare costs are reduced while their employees enjoy broad access to care and services. Enrollment and eligibility assistance to help implement plans with minimal disruption and hassle. Claims and customer service with accurate claims adjudication and responsive support to participants, all backed by robust technology. Reporting and strategic services that help project claim costs, track trends, minimize liability and find opportunities for benefit plan and service efficiencies. Medically appropriate, cost-effective health care for complex conditions, giving your clients the best value for their healthcare dollar. Dedicated teams that deliver a full range of everyday services and expert account management. * Although most consumers who enroll in an HDHP are eligible to open an HSA, participants should consult with a financial adviser to determine if an HSA/ HDHP is a good financial fit for them. Blue Shield does not offer tax advice or HSAs. HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, consumers should ask their financial or tax adviser. HSA plan features may vary by institution and may be subject to change by those institutions. 5
PPO Plan Comparison PPO plans Highlights Blue Shield PPO 0/500-100/50 $20 copayment $0 deductible Blue Shield PPO 250-90/70 $10 copayment $250 deductible Blue Shield PPO 250-90/70 Value $15 copayment $250 deductible Blue Shield PPO 250-80/60 $20 copayment $250 deductible Blue Shield PPO 500-80/60 $35 copayment $500 deductible Copayment 100/50 90/70 90/70 80/60 80/60 80/50 percentage 2 Calendaryear medical deductible 2 Non-network Calendar-year copayment maximum 1 $0 $0 family $500 $1,000 family $2,000 $4,000 family Non-network $5,000 $10,000 family Office visits (dollar/visit copayment not subject to calendar-year deductible) $250 $500 family $250 $500 family $2,000 $4,000 family $5,000 $10,000 family $250 $500 family $250 $500 family $2,000 $4,000 family $10,000 $20,000 family $250 $500 family $250 $500 family $3,000 $6,000 family $10,000 $20,000 family $500 $1,000 family $500 $1,000 family $3,000 $6,000 family $10,000 $20,000 family $20/visit $10/visit $15/visit $20/visit $35/visit 20% Non-network 50% 30% 30% 40% 40% 50% Inpatient hospital 3 No charge 10% 10% 20% $250/admission + 20% Non-network 50% 30% 30% 40% 40% 50% Outpatient surgery (hospital or an ambulatory surgery center that is affiliated with a hospital) No charge 10% 10% 20% $125/surgery + 20% Non-network 50% 30% 30% 40% 40% 50% Participating ambulatory surgery center 3 No charge 10% 10% 20% 20% 20% Non-network 50% 30% 30% 40% 40% 50% 8 Blue Shield PPO 2250 (HSAeligible HDHP) 2 No charge for preventive care $2,250 deductible $2,250 $4,500 family $3,000 $5,500 family (out-of-pocket maximum) 20% 20% Skilled nursing facility (in hospital) No charge 10% 10% 20% 20% 20% Non-network 50% 30% 30% 40% 40% 50% ER (not subject to the calendaryear deductible on services not resulting in a direct admission) $100 $100 + 10% $100 + 10% $100 + 20% $100 + 20% $100 + 20% (ER facility copayment does not apply) 6 See last page for endnotes. For exact terms and conditions of coverage, including exclusions and limitations, please refer to the Benefit Summary. This is an overview of the plan benefits offered. All plans are subject to limitations and exclusions. Services may require prior authorization by Blue Shield. When services are prior authorized, participants pay the preferred or participating amount.
Two pharmacy plan options 10/25/40 with $0 deductible 15/30/45 with $150 deductible Blue Shield is its own pharmacy benefits manager (PBM) and is able to deliver greater savings to customers. Plus, Blue Shield s GenericSmart SM program promotes generic medications, which are just as safe and effective as their brand counterparts, but can cost 50% to 60% less. Outpatient prescription drug plan options for Blue Shield plans 3-tier options formulary Calendar-year brand-name drug deductible 1,2 options (per participant) Copayment per prescription from a network pharmacy (up to 30-day supply) Formulary generic drug None $10 $20 Formulary brand-name drug $25 $50 Non-formulary brand-name drug $40 $80 Formulary generic drug $150 $15 $30 Formulary brand-name drug $30 $60 Non-formulary brand-name drug See last page for endnotes. $45 $90 Copayment per prescription from the mail service pharmacy (up to 90-day supply) 7
Blue Shield network advantages Your clients benefit from Blue Shield s contracted network rates, which are among the best in California. Through strategic provider contracting, we deliver demonstrable cost advantages, with a better average unit cost for hospital inpatient, hospital outpatient, and professional services. Blue Shield s PPO network is one of the largest PPO networks in California. When you pair that with access to national and international networks of providers through the Blue Card Program and the BlueCard Worldwide, your clients are well covered. Eighty-five percent of all providers in the United States belong to the BlueCard national network, and more than 50,000 providers in 200 countries belong to BlueCard s Worldwide Program. So, participants can have access to care wherever they go. Get the total picture on network value Historically, evaluations of a health plan s network have been focused on claims paid at in-network benefit levels to contracted providers to determine the value of negotiated agreements between the health plan and its network providers. While this traditional method represents an accurate picture of those claims measured, it doesn t provide your clients with the true network value. By not including out-of-network claims and claims paid to non-contracted providers, the claims analysis typically only measured network value on 85% to 97% of the health plan s claims. To get the total picture on network value and accurately gauge total cost savings, your clients should apply the Total Discount Measurement 1 (TDM) method. This method moves beyond the traditional model of measuring to one that is data driven and accounts for the full value of the health plan s networks by measuring the discount off billed charges as a function of all claims. Contracting Status Contracted Non-Contracted Total Discount Measurement includes all claims Benefit Payment In- Out-of- In- Contracted Out-of- Contracted In- Non- Contracted Out-of- Non-Contracted Account for all the claims Ultimately, total discounts are affected by the percentage of claims paid at in-network and out-of-network benefit levels as well as the use of both contracted and non-contracted providers. An evaluation that incorporates all claims regardless of benefit payment or provider contracting status offers the best representation of the employer s future claims spend and provides the most complete discount analysis for carrier selection. 5% of out-of-network claims not measured represent a 2.5% discount differentiation. 8
Total discount view at Blue Shield Blue Shield s research shows that our negotiated rates are as good as or better than the average of competing carriers in all California markets when using the Total Discount Measurement approach. Sample markets Blue Shield negotiated rates 2 San Francisco Bay Area Sacramento/Central Valley Los Angeles, Orange, and Coastal areas Up to 5% better Up to 7% better Up to 5% better When your client couples our favorable negotiated rates with the size of the network (which is one of the largest), the fact that Blue Shield s provider networks have increased 17% over the last six years 3, and provider turnover rate was only 2% last year 3, we think you ll agree that Blue Shield s network provides an exceptional value for your clients. Because Blue Shield has one of the largest networks, more claims are paid at in-network rates. The Blue Shield Total Discount Measurement applied 2 Blue Shield Average Negotiated Rate Advantage Average Claims Savings Annual Savings 4% 8% $2M* * Based on 5,000 employees and an average billed charge of $10,000 per employee per year. 1 The Total Discount Measurement analysis is reproduced with the express written permission of the Consortium Health Plans. 2 Results based on Blue Shield market research, Consortium Health Plans data, coordination of benefit, and claim repricing analysis. Individual client results will vary based on specific account location, providers used, and competing carriers as of Q1 2011. 3 Based on Blue Shield network management data at Q2 2011. 9
Services and support When clients select a Blue Shield level funded or an ASO plus stop-loss insurance arrangement*, they can count on a wide range of services and support to help them contain costs and help keep employees healthy and productive. All of these programs are integrated into a common technology platform that enables greater program coordination and a seamless experience for participants. Reporting: transparency in numbers Clients who want a more active role in managing their benefit plan will value the regular array of reports that will help them drill down into what drives their healthcare costs and, in turn, what they can do to better manage them. Standard reports include: High-dollar claims Trigger diagnosis Aggregate claims Comprehensive care management Blue Shield s level funded or ASO plus stop-loss insurance arrangements* come with integrated services and support aimed at the most appropriate care and programs that deliver effective guidance toward cost-effective utilization. From prevention to risk reduction, through early discovery and meaningful interventions, Blue Shield helps to keep employees healthy and assists those with illness to recover and live better. Key programs included with midsize alternate funded solutions include: disease Management is designed to help participants manage their chronic conditions, improve their quality of life, and minimize the cost of health care. Participants with these conditions will benefit: heart failure, coronary artery disease, chronic obstructive pulmonary disease (COPD), diabetes, or asthma. The programs help participants manage their chronic condition through a unique combination of at-home monitoring, education, and nurse-patient relationships. Participants are offered personalized services tailored to their needs, including printed education and self-management materials, 24/7 access to the online Care Center, and unlimited toll-free telephone access to a nurse. Nurses closely monitor higher-risk participants through scheduled outbound calls and/or at-home monitoring to avoid costly complications and support optimal quality of life. High Risk and Chronic Complex Case Management programs are designed to improve quality of care and reduce cost. These programs are for select participants with complex conditions and chronic diseases requiring a wide range of specialtized care from numerous providers. Participants may include those with multiple comorbid conditions, advanced-stage cancer, acute circulatory and digestive conditions, end-of-life/hospice care, neonatal intensive care, catastrophic injury, and more. NurseHelp 24/7 SM provides confidential, secure access to registered nurses anytime, day or night, putting participants in better control of their health decisions. Whether it s about healthcare assistance, self-care guidance, preparation for physician office visits, health education, or practical information about chronic conditions, NurseHelp 24/7 can help. Member appeals If an enrollee of a self-funded plan has a dispute with their plan, federal law mandates certain requirements for plan sponsors to follow regarding appeals. For both the level funded and ASO plus stop-loss insurance arrangements, Blue Shield will process both the internal and external reviews for the client to be in compliance with the federal law. Client responsibilities: Clients using self-funding options are subject to legal requirements under ERISA and other applicable law. As your clients consider self-funding options, they should talk to their legal counsel regarding these requirements. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life) 10
Wellness discount programs * Your clients can encourage wellness among their employees with a range of value-added programs to help them stay healthy and save money at no additional cost to clients or participants. Program Diet and Exercise 24 Hour Fitness, ClubSport and Renaissance ClubSport Weight Watchers Non-prescription drugs Drugstore.com Alternative care Acupuncture Chiropractic Massage therapy Vision Exams, lenses, and frame discounts LASIK Description and discounts Discounts on membership and gym fees, including waived enrollment and processing fees Special pricing on membership rates for local meetings, at-home kits, and online program savings 5% off non-prescription drugs 15% off herbal vitamins and supplements in the natural supplement line 15% discount for contact lenses (first-time customers) and 5% discount for subsequent orders 5% back in rewards for every dollar spent (with participation in the drugstore.com dollars program) 25% discounts for services 20% discount at participating providers 15%-20% off LASIK and PRK vision correction surgery through participating providers * These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of the Blue Shield health plans apply. The network of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity nor efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield health plan covered benefits. Participants should access those covered services prior to using the discount program. Participants who are not satisfied with products or services received from the discount program may use Blue Shield s grievance process described in the Grievance Process section of the Benefits Booklet. Blue Shield reserves the right to terminate these discounts at any time without notice. Discount programs administered by or arranged through the following independent companies: Alternative Care Discount Program - American Specialty Health s, Inc. (ASH s) Discount vision discount program MESVision LASIK - Laser Eye Care of California, LLC, QualSight, Inc., and TLCVision Corporation Weight control- Weight Watchers North America Fitness facilities 24 Hour Fitness, ClubSport, and Renaissance ClubSport Health products (excluding prescription drugs) drugstore.com Talk to your self-funded or fully insured midsize clients about Blue Shield s level funded or ASO plus stop-loss insurance arrangements today. 11
Endnotes PPO plans 1 Participant is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield s allowable amount as full payment for covered services. Non-preferred providers can charge more than these allowable amounts. When participants use non-preferred providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar-year deductible or copayment maximum. 2 Although most consumers who enroll in an HDHP are eligible to open an HSA, participants should consult with a financial adviser to determine if an HSA/ HDHP is a good financial fit for them. Blue Shield does not offer tax advice or HSAs. HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, consumers should ask their financial or tax adviser. HSA plan features may vary by institution and may be subject to change by those institutions. 3 For semi-private room and board, medically necessary services and supplies. Outpatient prescription drug plan options 1 If the participant requests a brand-name drug when a formulary generic drug equivalent is available, the participant is responsible for paying the difference between the cost to your client of the brand-name drug and its formulary generic drug equivalent, as well as the applicable formulary generic drug copayment. For retail prescriptions (for up to a 30-day supply) from a non-network pharmacy, the participant submits prescription drug claims to Blue Shield Pharmacy Services and is responsible for 25% of the allowed charges in addition to the stated copayment for covered prescriptions. 2 The calendar-year brand-name drug deductible is per participant per calendar year as it applies to covered brand-name and specialty drugs. An Independent Member of the Blue Shield Association A43477-REV (7/11) blueshieldca.com