Partial Self Funding and Population Health Management. Facts, Concepts, and Strategies

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1 Partial Self Funding and Population Health Management Facts, Concepts, and Strategies Spring-Summer 2016

2 Agenda Framing the Conversation Opportunity provided by the ACA How do Fully Insured / Self Funded Plans compare? ERISA Financial Breakdown of Self Funded Plans: A Review of Individual Components What is Stop Loss Insurance? What are my network options? How do you choose a Third Party Administrator? Underwriting Partially Self Funded Plans Risk Sharing Strategies Strategies for Health Improvement and Cost Reduction Claim Auditing On Site Clinic Restricted Networks Reference Based Pricing Telemedicine Medical Tourism Sample Population Health Management

3 Framing the Conversation Fees Health Insurance Tax (HIT) 1/1/2014 Risk Adjustment Program 1/1/2014 Plan Year Effective Date Public Exchanges Self-Insured Health Plans Cadillac Tax 1/1/2018 Patient-Centered Outcomes Research Institute (PCORI) Fee 1/1/2014 Transitional Reinsurance Fee 1/1/2014 Coverage Requirements Access to Clinical Trials 1/1/2014 Coverage of Contraception 1/1/2014 First Dollar Coverage of Preventative Health Services, Screenings (Adults, Women, Children) 1/1/2014 Prohibition of Preexisting Conditions Exclusions 1/1/2014 Prohibition on Maintaining Lifetime Limits On Dollar Value of Benefits 1/1/2014 Coverage of Dependent Children up to 26 years old After 9/23/10 Emergency Services without Prior Authorization After 9/23/10 Required Plan Provisions Annual Limitation on Deductibles 1/1/2014 Essential Health Benefits Requirements (EHB) 1/1/2014 Guaranteed Issue 1/1/2014 Medical Loss Ratio (MLR) Mandate 1/1/2014 Rating Limitations based on Age, Smoking and Metropolitan Area 1/1/2014 Automatic Enrollment (applies to businesses with 200+ FTEs) 1/1/2014 Annual Reporting to HHS; Disclosure to Plan Enrollees 1/1/2014 Penalty for Employers who do NOT offer coverage (applies to businesses with 50+ FTEs) 1/1/2014 Penalty for Employers who offer unaffordable coverage 1/1/2014 Prevention and Wellness Program Rules 1/1/2014 Reporting Requirements to HHS and Plan Enrollees 1/1/2014 Restrictions on Annual Limits on Dollar Value of Benefits 1/1/2014 Waiting Period Restrictions Limited to 90 Days 1/1/ Level Internal and External Appeals Process After 9/23/10 Prohibition of Discrimination Based on Salary After 9/23/10 Adopt New Healthcare Information Technology (HIT) Procedures TBD ACA exchange requirements will add 3-20% increase to premiums Center Forward and Milliman, May 30, 2013

4 Fully Insured vs. Self-Funding, An Overview Fully Insured Partial Self Funding 100% Non-Refundable Premium Budget flat payments Expected Claims + Aggregate Corridor Stop Loss Premium PPO Rental Fee Third Party Administration (TPA) Pharmacy Benefit Management (PBM) Care Management Software Commission

5 3 Core Risks of Partial Self Funding What if one of my employees has a $1,000,000 claim? What if none of my employees have a catastrophic claim, but they all have moderately high claims? What if I want to terminate my self-funded plan?

6 High Level Advantages of Partial Self Funding Third Party Administration Cost and Utilization Controls Cash Flow Network Options Plan Design Data and Benchmarking Reduced Carrier Profit Margin Lower Operating Costs Risk Management Premium Tax Uniform Regulations (ERISA)

7 Potential Employer Concerns Perceived increased risk retention stop loss coverages can reduce and eliminate risk. Increased administrative responsibility more data = more opportunity for strategic thinking and better decisions

8 Opportunity for Cost Reduction Risk Management Programs Technology Partners Partially Self Funded plans allow for management of each plan component Claims Administration Risk/Reinsurance

9 Why is Stop Loss Important? Minimizes financial risk Limits responsibility and liability for healthcare charges Improves cash flow flexibility

10 Types of Stop Loss Specific Stop-loss Protects against individual large claimants that exceed a dollar limit (specific deductible) that the employer selects and is agreed to by the stop-loss carrier. The employer determines the specific deductible. The specific stop loss would advance or reimburse covered expenses over and above the specific deductible.

11 Types of Stop Loss Aggregate Stop-loss Works in tandem with the specific stop loss by insuring all eligible claims under the specific deductible. The stop-loss carrier sets the aggregate deductible based on the employer s group demographics, past claims experience and plan design. If total eligible paid claims exceed this aggregate deductible then the aggregate stop loss would advance or reimburse all eligible claims. Aggregate coverage protects the plan from exceeding an annual budgeted dollar amount, by providing a worst case scenario for claims costs.

12 How Specific and Aggregate Work Together AGGREGATE SPECIFIC $385 K Reinsurance Paid $110 K $75,000 Specific Deductible 25 K 10 K 75 K 100 K 50 K 85 K 150 K Employer Paid $275 K 75 K 50 K 75 K 75 K EE1 EE2 EE3 EE4

13 Defining a Stop Loss Contract VERY IMPORTANT! Claims Incurred Date versus Claims Paid Date Claim Lag

14 Common Contract Types 12/12 Incurred in 12 / Paid in 12 15/12 Incurred in 15 / Paid in 12 18/12 Incurred in 18 / Paid in 12 24/12 Incurred in 24 / Paid in 12

15 Common Contract Types 12/15 Incurred in 12 / Paid in 15 12/18 Incurred in 12 / Paid in 18 12/24 Incurred in 12 / Paid in 24 Paid Incurred anytime / Paid in 12

16 Common Stop Loss Riders Terminal Liability Option (TLO) Aggregating Specific Laser(s) Specific Advance Aggregate Accommodation

17 Aggregate Accommodation Example. Accrued Client Claim Payments Can Never Exceed the Accrued Aggregate Deductible Accrued Aggregate Deductible Total Claims Payable Client Pays Accrued Client Payments Aggregate Pays Pay-Back Aggregate Carrier 1 $100,000 $0 $0 $0 2 $200,000 $200,000 $200,000 $200,000 3 $300,000 $200,000 $100,000 $300,000 $100,000 4 $400,000 $100,000 $100,000 $400,000 5 $500,000 $50,000 $100,000 $500,000 $50,000 6 $600,000 $50,000 $100,000 $600,000 $50,000 7 $700,000 $50,000 $50,000 $650,000 8 $800,000 $200,000 $150,000 $800,000 $50,000 9 $900,000 $150,000 $100,000 $900,000 $50, $1,000,000 $125,000 $100,000 $1,000,000 $25, $1,100,000 $100,000 $100,000 $1,100, $1,200,000 $125,000 $100,000 $1,200,000 $25,000 $1,200,000 $1,350,000 $1,200,000 $1,200,000 $250,000 $100,000

18 TPA s and Networks. Lot s of TPA options Service proposition? Included services? Network availability? Public / Private? Lots of network options PPO Preferred Provider Organization ACO Accountable Care Organization an organization of health care providers that agrees to be accountable for the quality, cost, and overall care. Narrow Networks Reference Based Pricing Employer sets price cap per service. Typically managed by TPA.

19 Underwriting Self Funded Plans Administration Maximum Claims Risk Stop Loss Premiums Maximum Claims Risk (Aggregate Deductible) = Expected claims + corridor Administration = Fee charged by the TPA, inclusive of the network and other ancillary services Stop Loss Premiums = Specific and Aggregate premiums set by carrier based on claims risk vs. deductibles

20 Basic Stop Loss Underwriting Example Annual Paid Claims per the FI renewal = $4,200,000 Aggregate Stop Loss Maximum Claims Projection (last years claims + 10% trend + 25% aggregate corridor) = $5,775,000 Projected Stop Loss Premium = $250,000 Projected Admin Fee = $75,000 Projected Broker Commission = $75,000 Total Self Funded Maximum Cost = $6,175,000 Total Renewal Fully Insured Premium = $5,229,257 Total Self Funded Costs IF Claims Same as Last Year = $4,600,000

21 Underwriting Self Funded Renewals Administration Maximum Claims Risk Stop Loss Premiums Maximum Claims Risk (Aggregate Deductible) = Expected claims + corridor Administration = Fee charged by the TPA, inclusive of the network and other ancillary services Stop Loss Premiums = Specific and Aggregate premiums set by carrier based on claims risk vs. deductibles Is the renewal offer fair based on the data? Most years, self funded plans incur far less in claims than their Aggregate Deductible

22 What is Level Funding? Annual Administration Annual Maximum Claims Risk Annual Stop Loss Premiums TOTAL Maximum Annual Cost for the year broken down into 12 equal monthly payments Most products offer run-out protection in the event of termination After the end of the run-out period, client is reimbursed unused claims dollars

23 Selling the Concept Expected Costs vs. Maximum Costs Costs based on group performance not insurance pool Personalized Service through a TPA Transparent claims and cost structure enables more strategic decision making Ability to better negotiate stop loss renewals

24 Selling the Concept Access to all claims and cost information Tailored reports Same benefits, same payer Cash flow management Potential financial savings over time

25 Common Risk Sharing Strategies Consortiums Captives MEWA Potential Advantages potentially less volatility in overall / ongoing plan costs due to economies of scale. Healthy groups subsidize unhealthy. Potential Disadvantages Multi-year commitments to try and avoid the potential for the healthiest companies to leave each year.

26 Emerging Strategies for Cost Reduction Claim Auditing available automatically from TPA but more intense from other vendors, which may include aggressive plan document language and legal back up. Pricing Transparency allows employees to research quality and price. Incentives drive utilization. Telemedicine telephonic and web based doctor and Rx consultations. Medical Tourism highest quality is often lowest price. Incentives drive utilization. Onsite Clinic PCP as gatekeeper. Steerage to high quality/low cost specialty care. Incentives drive utilization.

27 Emerging Strategies for Cost Reduction Population Health Management An example: Client/Consultant Predictive Analytics Portal Health Coaching Wellness Programs Member Pricing Transparency Tools Incentive/Wellness Management Online Member Portal with Mobile Application

28 Predictive Analytics Risk Profile & Potential Cost Analysis for Sample Company

29 Predictive Analytics Risk Profile & Potential Cost Analysis for Sample Company

30 Sample Incentive Design

31 Ways to Earn Points

32 Member Portal Makes it Easy for the Member

33 50/50 Rule finding the right prospects Fully insured pools allow sicker companies to pay less while healthier companies pay more. 50% of the members of the pool are paying too much being fully insured 50% of the members of the pool are paying too little being fully insured Using simple logic, 50% of the companies you meet with would likely save money in the long run as they have better than average risk. Smaller groups will experience stricter underwriting from stop loss carriers than larger groups as the larger the group becomes, the more stop loss premium is charged.

34 Questions or need more information? Please Contact: John Augustine

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