SELF-INSURED PLANS. A Report Prepared for the Legislative Finance Committee. By Kris Wilkinson

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1 SELF-INSURED PLANS A Reprt Prepared fr the Legislative Finance Cmmittee By Kris Wilkinsn September 24, 2015

2 INTRODUCTION As part f its wrk plan fr the 2017 interim the Legislative Finance Cmmittee (LFC) included develping an understanding f the financial cnditin f the state emplyee and Mntana University System (MUS) grup benefit plans. The LFC requested a reprt n hw Mntana state self-insured pls perate as part f its examinatin. The purpse f this reprt is t prvide the LFC with infrmatin n: Reasns why emplyers self-fund health plans Purpse f the state self-funded plans Statutry requirements Impacts f the Patient Prtectin and Affrdable Care Act (PPACA) Cmparisn f the state emplyee and university grup benefit plans including: Demgraphics f beneficiaries Plan ptins Financial cnditin f plans at FYE 2015 Open enrllment ptins Participatin in emplyee health care clinics Areas fr further cnsideratin REASONS WHY EMPLOYERS SELF-FUND PLANS Self-insured plans are funded by emplyers and emplyee cntributins held in a reserve, rather than purchasing a health insurance plicy fr emplyee and dependent health care benefits frm private insurance cmpanies. In ther wrds the emplyer assumes the financial risk fr prviding health care benefits fr its emplyees and their dependents. The emplyer may cllect cntributins twards the csts f the health plan frm emplyees r fund the health plan entirely. The emplyer must make the payment f medical claims fr its emplyees and eligible dependents in accrdance with the benefits utlined in the summary plan dcument. At their ptin emplyers can cntract services with a third party administratr such as: enrllment, claims prcessing, and access t financial arrangements with prviders thrugh prvider netwrk agreements via a cntract. Characteristics f self-funding fr health care benefits include: Cntrl ver health plan reserves including the interest generated frm the reserves which can be used t lwer the csts f prviding health care benefits Exceptins t insurance reserve requirements which can als lwer the cst f prviding benefits Ability t custmize the benefits t the health care needs f the emplyees Ability t administer prvisins f the benefit plan t meet the needs f the emplyer and its emplyees Imprved cash flw as prepayment fr the insurance cverage is nt required Regulatin is at the federal level under the Emplyee Retirement Incme Security Act (ERISA) s that the emplyer is nt subject t state health insurance regulatins. State and lcal gvernments are specifically excluded frm the ERISA requirements Exemptin frm state health insurance premium taxes which in Mntana are 2.75% f net premiums Exemptin frm health insurer tax required in the Patient Prtectin and Affrdable Care Act which is currently 2.5% Ability t develp custmized prvider netwrks r cntracts with prviders that serve emplyers wrkfrce needs Legislative Fiscal Divisin 2 f 9 September 25,2015

3 LEGISLATIVE PURPOSE IN ESTABLISHING SELF-INSURED PLANS FOR STATE AND UNIVERSITY EMPLOYEES As utlined in statute, the purpse f the state grup insurance is t establish a prgram under which the state may prvide state emplyees with adequate grup hspitalizatin, health, medical, disability, life, and ther related grup benefits in an efficient manner and at an affrdable cst. Statute allws the Bard f Regents t transfer its authrity fr prviding grup benefits fr emplyees f the Mntana University System t the Department f Administratin. The Bard f Regents has nt elected t transfer its authrity and as a result the state has tw separate self-insured plans fr its emplyees, ne fr Mntana University System emplyees and ne fr all ther state emplyees including legislatrs. STATUTORY REQUIREMENTS Federal Statutes As discussed under Reasns Why Emplyers Self Fund Plans, mst self-insured plans cme under the requirements f the Emplyee Retirement Incme Security Act. ERISA prvides emplyees cvered under self-insured plans participant rights including: Prviding plan infrmatin t plan participants cmprised f a plan summary, annual reprt, rules, financial infrmatin, and infrmatin n the peratins and management f the plan Timely and fair prcess fr benefit claims Ability t cntinue grup health cverage if emplyee lses cverage under certain circumstances Ability t recver benefits prvided by the plan Prvisin f a certificate evidencing health cverage under the plan While state and lcal gvernments are exempted under ERISA bth the state emplyee and Mntana University System emplyee benefit plans prvide similar participant rights In additin self-insured grup health plans must cmply with applicable federal statutes included in: Health Insurance Prtability and Accuntability Act (HIPAA) Cnslidated Omnibus Budget Recnciliatin Act (COBRA) Patient Prtectin and Affrdability Care Act (ACA) Genetics Infrmatin Nn-Discriminatin Act (GINA) Americans with Disabilities Act (ADA) Pregnancy Discriminatin Act Age Discriminatin Act Civil Rights Act Plans may als cme under requirements cntained in federal budget recnciliatin acts. While the majrity f the statutes have been fully in effect fr a number f years the ACA requirements were implemented beginning March 28, 2010 (with certain lk-back prvisins t September 23, 2009) thrugh 2018 and thus the full impact f the changes n the state s grup benefit plans have nt yet been realized. The fllwing sectin discusses the ACA requirements that apply t all self-insured plans. Legislative Fiscal Divisin 3 f 9 September 25,2015

4 Impacts f the Patient Prtectin and Affrdability Care Act Bth the state emplyee and Mntana University System grup health plans must fllw certain prvisins f the ACA. The majrity f the requirements were nt included as part f the plans prir t adptin f the ACA. It shuld be nted that with the exceptin f the excise tax n high value plans the ther majr requirements have taken effect and have been in place at least since These include: Expanding cverage f dependents t age 26 Open enrllment fr dependent children up t age 18 Cvering 100 % f preventative health services Eliminatin f prir authrizatin and higher ut-f-netwrk cpayment r cinsurance rates if cvering emergency services Eliminatin f any requirements that primary dctrs refer wmen fr bstetrical and gyneclgical care allwing wmen t btain services frm the prvider f their chice Cverage fr individuals participating in apprved clinical trails Essential health benefits nly limited as permitted by federal r state law Eliminatin f lifetime benefit limits fr essential health benefits Prhibitin n rescinding benefit cverage unless fraud r intentinal misrepresentatin ccurs Prviding fr cntraceptive cverage at n cst t the beneficiary Prhibitin n discriminating health care benefits based n preexisting cnditins r health status Mental health and substance abuse disrder services parity if services prvided by the plan Limitatins n cst sharing and ut-f-pcket spending Payment f a cmparative effectiveness research fee which was $1 f the average number cvered lives in 2013 and $2 f the average number f cvered lives in This prvisin sunsets in FY 2019 Unifrm explanatin f cverage dcuments and standardized definitins Requires internal and external appeals prcess ACA Emplyer Shared Respnsibility Requirements - Penalties if emplyees receive premium credits thrugh an exchange and the emplyer des nt ffer cverage. In 2014 this is determined by the number f full-time emplyees minus 30 multiplied by $ per emplyee per applicable mnth. After 2014 the penalty is indexed by the premium adjustment percentage fr the calendar year ACA Emplyer Shared Respnsibility Requirements - Penalties if emplyer ffers cverage but the emplyee s required cntributin exceeds 9.5% f the emplyee s husehld incme r if the plan play fr less than 60% f cvered expenses. In 2014 this is determined by the number f full-time emplyees that receive the credit multiplied by $250 fr any applicable mnth. Ttal penalty is limited t the penalty paid if emplyer des nt prvide cverage as discussed abve Subject t excise tax (als referred t as the Cadillac tax) f 40% f the value f the plan that exceeds threshld amunts. Fr 2018 high-cst health plans are plans that the aggregate value f the plan exceeds $10,200 fr single cverage r $27,500 fr cverage tiers ther than single. Aggregate value includes reimbursements under a flexible spending accunt, emplyer cntributins t a health savings accunt, emplyer and emplyee cntributins r premiums t health care plans Reinsurance fee f $63 per eligible participant per year. Cst estimated t be $1.04 millin in FY 2014 fr the state emplyee grup health plan and $1.04 millin fr the Mntana University system emplyee health plan. This requirement expires in 2016 Legislative Fiscal Divisin 4 f 9 September 25,2015

5 A number f the prvisins such as expanding cverage f dependents t age 26, eliminatin f lifetime maximum limits, and eliminatin f pre-existing cnditin exceptins added t the csts f bth plans. Mntana Statutes By law, bth the state emplyee and Mntana University System grup benefit plans are exempted frm statutry prvisins n insurance and insurance cmpanies fund under Title 33. Bth the Bard f Regents and the Department f Administratin are required, if they implement alternatives t cnventinal insurance, t maintain the alternative plans n an actuarially sund basis. It shuld be nted that bth plans have elected t prvide grup health benefits thrugh a self-insurance mdel. Statute als prvides fr certain health plan requirements including: Annual cpayment and deductible prvisins that are subject t the same terms and cnditins applicable t all ther cvered benefits within a given plicy Written infrmatinal materials n cancer screening cverages Cverage fr hspital in-patient care fllwing a mastectmy, lumpectmy, r lymph nde dissectin fr the treatment f breast cancer Outpatient self-management training and treatment fr diabetes management including $250 benefit fr training and educatin and cverage fr diabetic equipment and supplies Cmpliance with statutes that utline the cverage f rutine patient csts fr participants in cancer clinical trials COMPARISON OF THE STATE EMPLOYEE AND MONTANA UNIVERSITY SYSTEM GROUP BENEFIT PLANS While bth plans ffer a variety f benefits including medical, dental, visin, and life insurance fr cmparisn purpse this prtin f the reprt is fcused n medical benefits prvided by each plan. Demgraphics f Beneficiaries Demgraphics f a plan can impact health care csts. Fr example, it is generally understd that yunger individuals have lwer healthcare csts when cmpared t individuals wh have retired. In additin certain types f emplyment r extra-curricular activities pse a greater risk f injury than thers. While wrkplace injuries are insured thrugh wrkers cmpensatin insurance extracurricular activities wuld be insured thrugh the grup health plans. State Emplyee Grup Benefit Plan (SEGBP) State emplyees, retirees, legislatrs, elected fficials, judges, and eligible dependents are eligible fr benefits if the emplyee qualifies fr cverage. Part-time r seasnal emplyees must wrk 20 hurs r mre a week cntinuusly fr six mnths r mre t qualify. The state emplyee grup benefit plan averaged the fllwing number f eligible participants in its medical plan in 2014: Active emplyees - 12,874 COBRA participants - 28 Retired emplyees under Retired emplyees ver 65 2,415 The majrity f the active emplyees under this plan are emplyed by the Executive Branch. Accrding t the Calendar Year 2014 State Emplyee Prfile, the average age f the Executive Branch emplyees was 46 in In additin the majrity f the emplyees in state emplyment are included in the bradband pay plan. The reprt als states that 70% f the emplyees in the pay plan hld psitins requiring a bachelr s degree r equivalent educatin and experience. Legislative Fiscal Divisin 5 f 9 September 25,2015

6 It shuld be nted that the type f emplyment varies greatly amng the varius state agencies. Fr example prisn guards, psychiatric technicians, painters, budget analysts, and administrative assistants are amng the variety f state psitins. Mntana University System Grup Benefit Plan (MUSGBP) Individuals emplyed by a unit f the Mntana University System, the Office f the Cmmissiner n Higher Educatin, r ther agency r rganizatin affiliated with the Mntana University System f the Bard f Regents f Higher Educatin are eligible t participate if: Permanent faculty r prfessinal staff members scheduled t wrk at least 20 hurs per week r 40 hurs ver tw weeks fr mre than 6 mnths f any year Temprary faculty, prfessinal staff, r seasnal faculty wh wrk at least 20 hurs per week r 40 hurs ver tw weeks cntinuusly fr at least six mnths r mre Academic r prfessinal emplyees with an individual cntract under the authrity f the Bard f Regents that meets eligibility under the ther requirements The Mntana University System grup benefit plan averaged the fllwing number f eligible participants in its medical plan in 2014: Active emplyees and dependents 15,369 COBRA participants 125 Retired emplyees and dependents under 65 1,150 Retired emplyees and dependents ver 65-1,768 The majrity f the active emplyees under this plan are emplyed by the Bard f Regents. The average age f MUS emplyees was als 46 in The Office f the Cmmissiner f Higher Educatin estimates that 75% f the emplyees in the system hld psitins requiring a bachelr s degree r equivalent cmbinatin f educatin and experience. Plan Optins fr 2015 The plan years fr the state emplyee and Mntana University System grup benefit plans are different: State emplyee grup benefit plan year is a calendar year frm January 1 t December 31 Mntana University System grup benefit plan year is a fiscal year frm July 1 t June 30 Fr this prtin f the reprt the plan year fr the SEGBP is calendar year 2015 while the MUSGBP is FY State Emplyee Grup Benefit Plan Emplyees under the SEGBP are eligible fr medical benefits thrugh a single third party administratr, Cigna. Mnthly plan cntributins fr a single active emplyee in plan year 2015 were $845 r $10,140 annually. HCBD staff discussed ptential increases fr cntributins, deductibles, cpayments, and cinsurance fr plan year 2016 with the State Emplyee Grup Benefit Advisry Cuncil (SEGBAC). Discussin included increasing cntributins frm $845 a mnth t $963 mnth r a 12.2% increase fr a single emplyee. It shuld be nted that at this level the annual cntributin wuld be $11,556 r $1,156 abve the high-cst health plan threshld fr the excise tax that takes effect in Mntana University System Grup Benefit Plan Emplyees eligible fr medical benefits under the MSUGBP are ffered a chice between three plan administratrs: Allegiance Blue Crss/Blue Shield Pacific Surce Legislative Fiscal Divisin 6 f 9 September 25,2015

7 Rates fr cverage and prvider netwrks vary between the three plans allwing emplyees t chse a plan that fits with their requirements. Deductibles, cpayments, cinsurance and ut f pcket limits are the same fr all three plan administratrs s that the benefits and cverage fr each administratr is cmparable. Mnthly cntributins fr a single emplyee fr each plan administratr in FY 2016 were: Allegiance - $624 Blue Chice - $610 Pacific Surce - $682 Financial Cnditin f Plans at FYE 2015 As discussed in Reasns Why Emplyers Self Fund Plans, reserve requirements required by state law are nt applicable t self-funded plans. Hwever, in bth cases the state self-funded plans have retained actuaries t determine the amunt f reserves the plan shuld retain t be financial sund. State Emplyee Grup Benefit Plan (SEGBP) In calendar year 2014, the financial health f SEGBP, as measured by the level f reserves, declined. This was due t a significant increase in medical claims that resulted in a decline in claims reserves f $24.2 millin. The actuary fr the plan recmmends a reserve level f $78.9 millin fr plan year The ending reserve level fr plan year 2014 was belw the level recmmended by the plan actuary by $16.9 millin. Plan Year 2015 Fr the first tw quarters f plan year 2015: Revenues fr the plan increased by 14.1% r $10.5 millin when cmpared t the same perid in plan year A prtin f the increase is due t higher cntributins fr cverage by the participant and the emplyer share f the cntributins made by the state f Mntana. Fr plan year 2015 the state share f the cntributins was increased by 10% frm $806 per mnth per emplyee in plan year 2014 t $887 per mnth per emplyee in plan year 2015 Expenditures fr the plan decreased 9.0 % r $8.1 millin when cmpared t the same perid in plan year $3.5 millin f the reductin is due a change in the estimate f incurred but nt reprted claims Plan reserves are prjected t be $51.7 millin at the end f the plan year, r $23.6 millin belw the actuarially recmmended level f reserves. This represents an additinal decline in plan reserves f $6.7 millin since December Plan reserves are prjected t increase by $1.0 millin in plan year 2015 Mntana University System Grup Benefit Plan MUSGBP ended FY 2014 with reserves that were $13.5 millin abve the level recmmended by the plan actuary f $36.7 millin. FY 2015 Medical and dental expenses exceeded revenues by 12.0%, in FY 2014 revenues exceeded expenses by 3.8% Plan lst $10.0 millin ver the plan year cmpared t an expected gain f $0 Lsses were mainly related t a large claims, mstly nenatal babies, Anther factr was a prescriptin drug trend ging frm an increase f 2.8% in FY 2014 t 21.0% in FY 2015 Reserves were $2.9 millin belw the level recmmended by the actuary in FY 2015 f $41.0 millin Legislative Fiscal Divisin 7 f 9 September 25,2015

8 Open Enrllment Optins Open enrllment whereby dependents can be added t the plan, can increase plan csts if dependents have chrnic health cnditins r serius health issues such as cancer. State Emplyee Grup Benefit Plan (SEGBP) The state emplyee grup health plan has had pen enrllment fr spuses and eligible adult dependents during its annual enrllment perid in plan years 2014 and 2015, and plan t cntinue this practice in plan year The plan had nt had pen enrllment fr seven years, and decided t fllw the natinal trend f having an pen enrllment. Accrding t 2015 State f Mntana Annual Change Bklet fr Emplyees The plan experienced an increase in claims spending. This is due t many factrs like last year s pen enrllment, which brught additinal members nt the Plan; a recrd number f members receiving health screenings and subsequently seeking care fr health cnditins f which they may nt have been aware; increases in the amunts charged by the hspitals; and mre. Mntana University System Grup Benefit Plan MUSGBP had: Clsed enrllment fr dependents in FY 2014 Clsed enrllment fr spuses and adult dependents in FY 2015 Clsed enrllment fr spuses and adult dependents in FY 2016 Participatin in Mntana Health Centers The state f Mntana began perating an emplyee health center in Helena August 31, Since then five additinal health center sites have been added in: Billings Miles City Missula Butte Anacnda Accrding t the Emplyee Health Clinics Frequently Asked Questins: Based n an independent actuarial analysis f the CareHere prpsal fr the Helena clinic, Mntana culd save ver $100 millin ver five years nce clinics are up and running statewide. The cst savings cmes in tw ways. First savings will cme frm the increased efficiency f paying fr care at cst instead f fee-fr-service. The secnd level f savings cmes as emplyees health imprves and catastrphic claims are reduced thrugh wellness, disease management, and chrnic care prgrams ffered at the clinics. As a means f increasing use f the emplyee health centers emplyees that receive care at ne f the health centers are nt required t pay deductibles r cpayments fr medical appintments r services. State Emplyee Grup Benefit Plan (SEGBP) The SEGBP funds the state health centers frm the cntributins made by emplyees and the state f Mntana t the plan reserves. The figure n the next page shws: Csts fr each health center frm inceptin thrugh February 9, 2015 Appintments by member s hme lcatin. The members mainly zip cde determines the lcatin, nt the actual health center visit lcatin Legislative Fiscal Divisin 8 f 9 September 25,2015

9 Department f Administratin Health Care and Benefits Divisin State Emplyee Health Clinics As f February 9, 2015 Inceptin Utilizatin as Clinic Date Appintments Cst f 2/21/2015 Billings 6/3/2013 8,732 $1,179,671 83% Butte 11/17/2014 5,648 $123,813 88% Helena 8/31/ ,876 $7,423,795 87% Miles City 9/24/2013 3,387 $567,902 36% Missula 5/27/2014 4,917 $516,099 85% Mntana University System Grup Benefit Plan Mntana University System emplyees may utilize services in the Helena clinic under a mem f understanding with SEGBP. AREAS FOR FURTHER CONSIDERATION The LFC has expressed interest in gaining a better understanding f the financial cnditin and cst drivers f the tw self-insured grup benefit plans. This reprt and the panel discussin by the administratrs f the plans may braden the LFC s understanding f hw the plans perate. Areas fr further LFC cnsideratin might include: Examinatin f the differences in benefits ffered by each f the state plans Cmparisn f utilizatin f services and csts between emplyees served within the state health center and thse utilizing ther prviders Csts assciated with adding dependents during pen enrllment perids prvided by SEGBP Results f analysis being cnducted by the SEGBP including: Awarding a cntract fr a third party administratr Examinatin f the state health centers Cst cntainment measures Actuarial review f the state health centers Other aspects f the plans as directed by the LFC Legislative Fiscal Divisin 9 f 9 September 25,2015

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