Safe and Simple Fixed‐Cost Self‐Funded Medical Coverage Plus Refund Assisters Overview June 15, 2017 June 15, 2017 Subject to Change Without Notice 1
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 stop-loss policies. All information in this presentation is subject to change without notice. In other words, we’ve tried to be accurate. If it’s wrong we apologize, but it’s not binding. Subject to Change Without Notice June 15, 2017 2
What Employers Want Something different … and better An advantage Something like fixed‐cost, self‐funded plans Subject to Change Without Notice June 15, 2017 3
Two Solutions Insurgency Benefits offers two safe and simple, fixed‐cost self‐funded medical coverage programs Subject to Change Without Notice June 15, 2017 4
Self-Funded Made Simple Self‐Funded can be complicated … … but it doesn’t have to be Subject to Change Without Notice June 15, 2017 5
Why Consider Self-Funding Claims lower than expected = refund Claims higher than expected = stop‐loss Heads clients win. Tails they don’t lose It’s that simple Subject to Change Without Notice June 15, 2017 6
Agenda 1. Self‐Funded Basics and Key Terms 2. Plans and Underwriting Overview 3. Resources 4. The Team 5. Questions and Answers Subject to Change Without Notice June 15, 2017 7
SELF‐FUNDING BASICS AND KEY TERMS June 15, 2017 Subject to Change Without Notice 8
Self-Funded Basics: Part I Traditional Insurance: • State regulation • Insurer pays claims – keeps surplus Self‐Funded Programs: • Federal regulation • Employer pays claims – keeps surplus Subject to Change Without Notice June 15, 2017 9
8 Key Terms Claims Fund … 1 Claims Surplus … 2 Stop‐Loss or Excess‐Loss Coverage … 3 • Specific Stop‐Loss … 4 • Aggregate Stop‐Loss … 5 Attachment Point … 6 Contract Period … 7 Run‐Out … 8 Terminal Liability Option (TLO) … 9 Subject to Change Without Notice June 15, 2017 10
Key Terms Claims Fund : money set aside by employers to pay claims Claims Surplus : money remaining in the claims fund after the contract period Subject to Change Without Notice June 15, 2017 11
Key Terms Stop‐Loss or Excess Loss Coverage : shields plan sponsors (employers) from excessive claims • Specific: caps claims on any one individual • Aggregate: caps overall claims Attachment Point : the claim amount at which stop‐loss coverage kicks‐in • Deductible for stop‐loss coverage Subject to Change Without Notice June 15, 2017 12
Key Terms Contract Period : time period during which eligible claims must be incurred and paid for to be covered by excess loss carrier • Expressed by two numbers: aa/bb beginning with start of contract • Incurred period (usually plan year) • Claims payment deadline 12/12 12/18 12/24 24/12 Subject to Change Without Notice June 15, 2017 13
Key Terms Run‐Out : time after the incurred period in which claims will be paid‐out under stop‐loss coverage • 12/18 has a six month run‐out • 12/24 has a 12 month run‐out • 12/12 has no run‐out Terminal Liability Option: provides stop‐loss protection at end of contract • Run‐out for policies without run‐out Subject to Change Without Notice June 15, 2017 14
Managing Variability Pure Self‐Funding : Employer replenishes claim fund as claims are paid out Fixed‐Cost Self‐Funding : Employer pays fixed monthly payment regardless of claims paid Fully‐Insured Plans : Employer pays fixed monthly premium regardless of claims paid Subject to Change Without Notice June 15, 2017 15
Self-funding Basics: Part II Traditional Insurance: • State‐by‐state plan design • Subject to all ACA fees and premium tax Self‐Funded Program: • Can offer one plan nationwide • Exempt from some ACA fees and pay premium tax only on excess‐loss coverage Subject to Change Without Notice June 15, 2017 16
Fixed‐Cost Self‐Funded Can look like traditional health plans Traditional aditional Fix Fixed-Cost d-Cost Fully Insur Fully Insured ed Self-Funded Self-Funded Comprehensive Medical Coverage Fixed Monthly Employer Costs So far so sim So far so simple le 17 Subject to Change Without Notice June 15, 2017 17
The Fixed‐Cost Self‐Funded Advantage What makes them different makes them better Traditional aditional Fix Fixed-Cost Self- d-Cost Self- Fully Insur Fully Insured ed Funded Funded Protects Employers When Claims Higher Higher Than Expected Who Gets Surplus When Claims Less Less Insurer Employer Than Expected Heads you w eads you win. Tails you don’ n. Tails you don’t lose. t lose. Subject to Change Without Notice June 15, 2017 18
PLANS AND UNDERWRITING OVERVIEW June 15, 2017 Subject to Change Without Notice 19
Safe and Simple Fixed-Cost Self-Funded Medical Coverage with Refund Assisters that improve the health of employees and the bottom line of employers Subject to Change Without Notice June 15, 2017 20
Self‐funding with training wheels • Safe and comfortable way for clients to start self‐funding medical coverage Mimics traditional insurance while delivering benefits of self‐funding Subject to Change Without Notice June 15, 2017 21
Safe and Simple Administrative Services: Meritain Health Safe Safe Stop-Loss Coverage: AM Best Rated “A” or higher 8 PPO Plan Designs: 5 Co-Pay & 3 HSA-compatible 1 Medical Network: Aetna Simple Simple 1 Pharmacy Network: OptumRx 1 Contract Period for each product line Subject to Change Without Notice June 15, 2017 22
Fixed-Cost, Self-Funded • Level premium payments • Composite rates Fix Fixed-Cost d-Cost • Claim costs advanced if exceed employer’s payments to-date • Employer finances claims Self-Funded Self-Funded • Stop-loss coverage caps employer risk (both specific and aggregate coverage) Subject to Change Without Notice June 15, 2017 23
Our Plans vs Traditional Level Premium Plans Other Le Other Level vel Pr Protect and otect and Pr Premium Plans emium Plans Secur Secure Plans Plans Fixed Monthly Costs Claim Surplus Partial-to-100% Partial-to-100% 100% 100% Refund ? Offer Refund Assisters Refund Assisters SM Subject to Change Without Notice June 15, 2017 24
Why Refund Assisters Matter All level-funded plans offer offer the chance to earn claim surplus refunds The Protect and Secure Plans helps deliver deliver them Subject to Change Without Notice June 15, 2017 25
Refund Assisters: Wellness Wellness rewards for employees and spouses • $100 reward for annual preventive exam • $100 reward chronic condition program Wellness campaign assistance Smoking cessation programs Provided through Healthy Merits, Meritain Health for Life, and Disease Management administered by Meritain Health Subject to Change Without Notice June 15, 2017 26
Refund Assisters: Chronic Condition Reward Program $25 each quarter employee or spouse complies with treatment and prescription protocols for: Asthma Hyperlipidemia (high cholesterol) COPD Congestive Heart Failure Diabetes Coronary Artery Disease Hypertension Members must be in compliance for all three months in a quarter. Members may qualify for multiple chronic rewards. Subject to Change Without Notice June 15, 2017 27
Refund Assisters: Telemedicine A low‐cost, quality alternative to an in‐office doctor visit that’s convenient, private, and fast using board certified, U.S.‐based physicians. Subject to Change Without Notice June 15, 2017 28
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 Subject to Change Without Notice June 15, 2017 29
Benefits: HSAs HSA 3000 HSA 4000 HSA 5000 Deductibles $3,000 $4,000 $5,000 Annual Max $5,000 $5,500 $6,000 Family 2x Co‐Insurance 80/20 Office Visits Primary and Specialty: 20% / Telemedicine: $10 In‐Network Only Prescriptions 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 Subject to Change Without Notice June 15, 2017 30
Benefits: Co-Pay Plans Co‐Pay 500 Co‐Pay 1000 Co‐Pay 2000 Co‐Pay 3000 Co‐Pay 4000 Deductibles $500 $1,000 $2,000 $3,000 $4,000 Annual Max $1,500 $3,000 $4,000 $5,000 $6,000 Family 2x Co‐Insurance 90/10 80/20 Office Visit Primary Care: $25 / Specialty: $50 / Telemedicine: $10 In‐Network Only Prescriptions Apply to medical deductible and out‐of‐pocket maximums Generic $10 Brand $35 Non‐Formulary 50% Specialty 35% up to $300 co‐pay per prescription Subject to Change Without Notice June 15, 2017 31
Recommend
More recommend
