PWC Self-Insurance Health Fund

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1 PWC Self-Insurance Health Fund Finance Department Human Resources November 23,

2 Background Today Managed Care decade begins Ten years of moderate rate increases for County 55% rate increase proposed by Aetna County piggy backs on School s Trigon Blue Cross/Blue Shield contract Kaiser Permanente enrollment frozen Park Authority joins PWC self-insured program County continues to be self-funded with Anthem Blue Cross/Blue Shield 1

3 What is Self Insurance? Employer assumes the role of the Insurance Company by assuming the financial risk of the program Purchase stop-loss reinsurance to cap claims expense on large, catastrophic payments on an individual covered by the plan Self-funded plans offer several financial advantages including lower retention fees (risk fees, profit factors, margins, etc.); state premium tax savings; ability to realize cash flow savings in years with favorable experience Exempt from state mandated benefits; more flexibility in setting plan design and plan administration; enhance management reports on claim payment and utilization The County s Self-Insurance Health Fund is an insurance business 2

4 How Our Business Operates Third-Party Administrator Anthem Blue Cross/Blue Shield administers the day-to-day operations of our Self-Insurance Program (approves, processes & pays claims, manages provider networks, and negotiates provider fees/discounts) Consultant Services Wells Fargo Insurance Services provides actuarial analysis of employee health data and financial liabilities (compiles & projects costs) County Staff A collaborative effort by Finance and Human Resource Staff 3

5 Plans Offered to Employees Anthem Blue Cross/Blue Shield HMO PPO Core PPO Enhanced Delta Dental Core Enhanced Kaiser Permanente Offered only to existing enrollees Vision Services Plan (VSP) 4

6 Cost Efficiencies PWC proactively manages its health care program Programs installed in recent years which have enabled the County to maintain a competitive but cost effective health insurance program Medical and Disease Management Programs My Health Advantage mailings to subscribers Emergency Room Utilization Management Programs Pre-Authorization for advanced diagnostic testing Medical Management and Step approval for expensive name brand prescriptions Generic Select Program (provides incentives for the use of generic drugs) Smoking Cessation Program Proof of legal relationship for dependents 5

7 Retiree Health Program Employees with 15 years of County service are eligible to remain in County s health plan until Medicare eligible (Age 65) Required by Code of Virginia (effective July 1, 2000) Net cost to County approximately $1.3 $1.5 million per year Approximately 358 retirees enrolled 6

8 Early Retiree Reinsurance Program Early Retiree Reinsurance Program (ERRP) Creates a temporary reinsurance program for employers providing health insurance coverage to retirees over age 55 who are not eligible for Medicare Program designed to encourage employers to retain retiree health insurance programs until State health insurance exchanges are created in 2014 Program will reimburse eligible employers for 80% of retiree claims between $15,000 and $90,000 Payments from ERRP may only be used to lower the cost for enrollees in the employer plan Approximately $5 billion of Federal funding available Effective Date: Date: now now thru thru January 1, 1,

9 Potential Claims Reimbursement Available County has fiduciary responsibility to manage health care costs County applied for ERRP benefits in July 2010 Notification of HHS application approval in late August 2010 Prince William County was one of first 2,000 nationwide employers to be approved Potential for up to $600,000 in claims reimbursement to offset health care cost increases as a result of mandated benefit changes required by Health Care Reform Initial payment announcements expected from HHS in Fall

10 Waivers in the Media Health & Human Services (HHS) has granted limited waivers to employer sponsored plans which do not meet minimum essential coverage These plans are generally referred to as "mini meds" because they offer limited benefits [McDonald's was the highest profile employer to receive a waiver] Waivers were issued to avoid the elimination of coverage before 2014 health insurance exchanges become effective 9

11 Other Provisions of Health Reform Issue 1099s for Corporate Service Providers Requires employers to provide an IRS Form 1099 to all corporate service providers receiving $600 or more per year for services or property (Currently, 1099s need only be generated for non corporate service providers and only for services) Workload impact for PWC disbursement staff Effective Date: Date: January 1, 1, Itemized deductions reduced for individual taxpayers Raises the threshold for itemized medical expense deduction from 7.5% of Adjusted Gross Income (AGI) to 10% of AGI for regular tax purposes (waived for age 65 and older for tax years 2013 to 2016) Effective Date: Date: January 1, 1,

12 Other Provisions of Health Reform Increased Medicare tax Increases the Medicare Part A tax rate on wages from 1.45% to 2.35% on earnings over $200,000 for individual taxpayers and $250,000 for married couples filing jointly Imposes a 3.8% Medicare tax on unearned income (i.e. interest, dividends, rental income, annuities, royalties, and capital gains) for higher income taxpayers (It is important to note for capital gains, the first $250,000 in profit from the sale of a personal residence won t be taxed, or the first $500,000 in the case of a married couple filing jointly) Example of 3.8% tax: A single executive making $210,000 a year sells his $300,000 ski condo for a $50,000 profit. His tax on the sale of that vacation home would amount to an additional $1,900 plus the capital gains tax he would have paid anyway Effective Date: Date: January 1, 1,

13 Potential Impact on Staffing Staff needed for health care reform/benefit counseling and administrative processing 1 FTE Human Resource Analyst II (Grade 15) Human Resources 1 FTE FRC Staff Accountant (Grade 15) Finance 2 FTEs by 2013 (Estimated cost of salary/benefits = $180,000) 12

14 Questions Finance Department Human Resources

15 Human Services & Health Care Reform Area Agency on Aging (AAA) At Risk Youth & Family Services (ARYFS) Community Services (CS) Department of Social Services (DSS) Housing and Community Development (OHCD) Prince William Health District (PWHD) Virginia Cooperative Extension (VCE) November 23,

16 Expansion of Public Programs Expansion of Medicaid to all individuals under age 65 with income up to 133% of Federal Poverty Level (FPL) based on modified adjusted gross income (AGI) 1 person ($14,404), 2 ($19,378), 4 ($29,327) All newly eligible adults will be provided essential health benefits States will receive 100% federal funding for 2014 through 2016 and reduced incrementally to 90% by 2020 and subsequent years States have option to expand Medicaid eligibility to childless adults beginning on 4/1/10 Increases Medicaid primary care payments to Medicare reimbursement rates Expansion of Family Access to Medical Insurance Security (FAMIS) and State reimbursement Beginning in 2015, States will receive a 23% increase in FAMIS matching funds (FAMIS is known nationwide as CHIP) FAMIS-eligible children unable to enroll in program due to enrollment caps will be eligible for tax credits in State health exchanges 15

17 Expansion of Public Programs Expansion of Medicare Part D prescription drug benefits $250 rebate to Medicare beneficiaries who reach the Part D Coverage Gap ( donut hole ) in 2010 Gradual phase down of donut hole to 25% by 2020 Additional coverage for preventive care services 10% bonus payments to Primary Care Physicians (PCP) and General Surgeons in health professional shortage areas from 2011 to 2015 Ex. $50M mandatory funding for Aging and Disability Resource Centers (AAA lead agency in Virginia) 16

18 Reductions in Medicare Benefits Reduction in Medicare Advantage Plan benefits Changes from a HMO to regular Medicare (A, B, D and/or a supplemental) Requires a letter from the plan to the consumer noting they have to change their plan which suggests they contact their local Medicare Counseling service (VICAP). May leave some people unable to afford care Reduction in Medicare payments to hospitals for hospital-acquired conditions and readmissions Hospitals will be fined if Medicare patient is readmitted within 30 days with same or hospital acquired condition Care coordination during discharge and the first 30 days will require better coordination between hospitals and local care coordinators at the AAA Reduction in Medicare Part B premium subsidies Duel eligibles (Medicaid and Medicare age and income) will be affected Medicare recipients whose monthly income is less that $1,239 would have to pay their Part B premium which is $ in If one cannot afford this, they will lose their Medicare Part B 17

19 Uncertainty The Governor has implemented the Virginia Health Reform Initiative (VHRI) with an Advisory Council directing six Task Forces focused on: Medicaid Reform Insurance Reform Delivery Payment Reform Purchasers Technology Capacity The Government Reform Commission Major changes in Medicaid effective

20 Predicting Costs Difficult Many unknowns Impacts are based on current information Possible that there will be some benefits Private sector may take some roles and responsibilities from local government agencies Revenues may increase for Medicaid Providers Sources Secretary of Health and Human Resources William A. Hazel, Jr., MD, presentation to the House Appropriations Committee entitled Health System Reform 2010 The Kaiser Commission on Medicaid and the Uninsured September

21 Medicaid Impacts on AAA Focus on coordinating the acute and long term care services utilized by adults 65+ and persons with disabilities (70% of all Medicaid costs) which will change care coordination service delivery in Aging to include working with adults of any age Rebalancing long term care from institutional to community living very complex Funds are increasing for Money Follows the Person Program (transferring people with Medicaid from a nursing home to the community) and Community Living Program (prevent Medicaid spend down, nursing home diversion) Aging currently receives funds for this program Nursing homes must ask residents if they want to transition to living in the community; if yes then Aging is contacted and a prescribed process begins (started October 1, 2010) Birmingham Green affected and in need of 1FTE, PWC portion =.2FTE No funds to administer (received four requests in Oct) Staff: 2.2 FTEs by

22 Medicaid Impacts on DSS New populations Adults under the age of 65 based on income Former foster care children up to age 26 regardless of income FAMIS Plan coverage increases for children Covers all Virginians under the age of 65 up to 133% of Federal Poverty Level Estimate of Virginians on Medicaid - 270,000 to 425,000 (36.5% increase) PWC residents on Medicaid Nov 2010 = 35, %+ = 48,976 Eligibility determination workload will increase, unknown how program will be administered and, if local, will fiscal impacts be covered? Staff: 21 FTEs by 2014 Effective Date: Date:

23 Medicaid Impacts on PWHD Long-term care (includes Personal Care) eligibility changes will increase the number of persons in need of PWHD assessments Safety net responsibilities for certain programs may increase due to insufficient number of private sector Medicaid providers Staff: 5 FTEs by

24 Medicaid Impacts on OHCD/VCE/ARYFS OHCD: Does not affect OHCD unless funding increases for the Medicaid Nursing Home Transition to the Community Program -- Money Follows the Person which may increase the number of vouchers OHCD must administer ARYFS: When Medicaid funding support is denied prematurely, cost for continuation of services may increase VCE: Not affected 23

25 Medicaid Reimbursements Programs licensed as Medicaid Providers may receive increased Medicaid reimbursement AAA: Woodbridge Senior Day Program CS: Crisis, Day Support, Detox for Pregnant Women, Early Intervention, Emergency Services, Substance Abuse, Vocational Services PWHD: Assessments, Immunizations, Obstetrics Service, Women Wellness Increased administrative duties for audits, billing and denial assistance Staff: 15 FTEs by CS 3 FTEs by PWHD 24

26 Medicare Impacts on AAA, CS &, PWHD Prince William County Government Increases the number of people requesting Medicare counseling called VICAP (known nationwide as SHIP) Medicare Part D benefits changes Medicare Benefits preventive services introduced Medicare Advantage plans changing Medicare Health Promotion and Disease Prevention benefits increases causing additional requests for outreach, program services and care coordination Hospital care transition may also utilize AAA care coordination very complex Increase in grant funds from Centers for Medicare and Medicaid Services may help fund needed positions but will administrative oversight of the funds will be necessary Staff: 3 FTEs by AAA 1 FTE by PWHD 25

27 Potential Impact on Staffing Staff needed for administration and service delivery AAA 5.2 FTEs anticipated $289,710 ARYFS (see DSS) CS 15 FTEs anticipated $1,004,074 DSS 21 FTEs anticipated $700,958 OHCD N/A PWHD 9 FTEs anticipated $256,769 VCE N/A Equipment Phone and computer enhancements Office space Total FTEs = 50.2 $2,251,511 (salary & benefits) Currently the administrative rules have not been written and it is uncertain what portion will be covered by Health Care Reform 26

28 Questions Area Agency on Aging (AAA) At-Risk Youth & Family Services (ARYFS) Community Services (CS) Department of Social Services (DSS) Housing and Community Development (OHCD) Prince William Health District (PWHD) Virginia Cooperative Extension (VCE)

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