HEALTH INSURANCE CONSULTING FEBRUARY 21, 2013

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1 1 HEALTH INSURANCE CONSULTING FEBRUARY 21, 2013

2 2 INSURANCE BROKER TOOLKIT Medical Dental Life Disability Vision Employee Assistance Program (EAP) Supplemental (AFLAC) Flexible Spending Account (FSA) Health Savings Account (HSA) Health Reimbursement Arrangement (HRA)

3 3 WHY USE A BROKER? Appointed with all the carriers One place to go to receive a quote from all carriers Brokers are paid by carriers No-cost expert advice Whether you go direct to a carrier or work through a broker, premium cost is the same Advice and service Strategic planning partnership with HR and Finance Partnership with the carriers Liaison between member and the carrier HR compliance resource

4 4 INDIVIDUAL VS. GROUP Individual Plan Subject to health underwriting A carrier can deny coverage In OR Oregon Medical Insurance Pool for those denied (not in all states) Group Plan No health questions 2 or more employees Employer pays at least 50% of premium Employee must work at least 17.5 hours 75% participation Must come on the plan by FOM following 90 days

5 5 CASE STUDY (CS) C0ST ISSUE Employer in business for 30 years Portland Family owned and operated 31 employees Business slow due to recession 19.4% increase in insurance premium

6 6 CS CURRENT BENEFITS Medical and Dental Contribution: Employer pays 100% for employees Employer pays 75% for dependents Eligibility: First of the month following 90 days Minimum of 24 hours Life Contribution: Employer pays 100% for employees

7 7 CS WHAT DETERMINES RATES? Size of the group (risk) Contribution Participation Utilization Average Gender Factor Industry Age Zip code Tobacco Plan Design

8 8 CS WHAT ARE MY OPTIONS? 1. We review the type of medical plan HMO Kaiser Managed Care Own hospitals and equipment Doctors are employees of Kaiser Majority of in-network benefits; Kaiser docs and Kaiser hospitals PPO Regence Blue Cross Blue Shield Very large network; Providence, Legacy, OHSU More flexibility Limited networks within the large network Doctors and service providers are contracted

9 9 CS WHAT ARE MY OPTIONS? 2. We look at the Components of the Plan Design Copay First dollar benefit; $10-$50 Deductible What you pay before insurance pays Coinsurance Cost sharing between you and carrier Out of Pocket Maximum Your 12 month exposure Alternative Care Chiro, Acu, Naturo Prescription Review Utilization

10 10 CS WHAT ARE MY OPTIONS? 3. We look at eligibility and contribution Pass more cost to employees? Look at 75% / 75% Raise eligibility requirements less on plan? Raise minimum hours worked requirement from 24 to 32

11 11 CS WHAT ARE MY OPTIONS? 4. We look at implementing a Health Reimbursement Agreement (HRA) Example: Employer raises the deductible on the plan from $1000 to $1500 premium is reduced When employee goes to doctor, he/she is responsible for 1 st $1000 of deductible. The next $500 is paid by employer. Employer sets aside funds to reimburse medical expenses Employees receive tax free reimbursement for qualified expenses (i.e., deductibles, coinsurance) Fixed expenses are now less for the employer

12 12 CS WHAT ARE MY OPTIONS? 5. We look at the health of the employee Stress Tobacco Usage Obesity Heart Disease Diabetes Are employees using the wellness benefits? Are employees using the emergency room? Are employees going in for preventive care?

13 13 CS WHAT ARE MY OPTIONS? 6. We look at dropping other lines of coverage or making them voluntary The company pays 100% for dental for employees and 75% for dependents; Is voluntary dental an option? The company pays 100% for life insurance. Is there enough cost savings with changing this benefit?

14 14 Current (SBG) Renewal (SBG) Revis Kaiser Kaiser Plan Name KP 1000/20 KP 1000/20 Tra Deductible (Ind / Fam) $1,000 / $3,000 $1,000 / $3,000 $1 Co-Pay $20 $20 Ann OOP Max (Ind / Fam) $2,000 / $6,000 $2,000 / $6,000 $3 Pre-Existing Waiting Period None None **Deductible Waived **Deductible Waived Medical Coverage PCP Office Visit $20** $20** Specialty Office Visit $20** $20** Urgent Care Visit $40** $40** Diagnostic X-Ray / Lab $20** $20** Imaging Services (PET, CT, MRI) $20** $100** Hospital Services 20% 20% Emergency Services 20% 20% Spinal Manipulation $20 / 12 Visits Max $20 / 12 Visits Max $35 Vision $20** Exam Only $20** Exam Only $25 Prescription Coverage RX 20/40 RX 20/40/60 Deductible None None Tier 1 $20 $20 Tier 2 $40 $40 Tier 3 N/A $60 Mail Order (90 Day Supply) 2 Co-Pays 2 Co-Pays Current Enrollment Employee Only 8 $ $ Employee & Spouse 8 $ $ Employee & Family 12 $1, $1, Employee & Children 3 $ $ * * Monthly Total $24, $29, Annual Total $297, $355, Annual Premium Difference $57, Percentage of Difference 19.42%

15 15 CS THE END RESULT We raised deductible from $1,000 to $1,500 We implemented an HRA for the deductible after the first $1,000 We reduced the prescription plan to a $30/50% Kept the contribution and eligibility the same Implemented a tobacco surcharge those using tobacco pay $50/mo more in premium than a nonsmoker; waived if enrolled in smoking cessation program We kept life and dental in place Premium increase went from 19% to 6%

16 16 BENEFIT OFFERING DECISION Employers offer benefits for several reasons: Recruitment Tough competition in certain markets More comprehensive benefits with more lines Obligatory Feel it is the company s responsibility It s always been done The plans have been in place for so long, fear of discontinuing and effecting morale Health conscious They care about the health and welfare of employees; increased productivity, presenteesim

17 17 LOSS OF GROUP COVERAGE If you lose your job and have a chronic illness and/or do not wish to be without benefits: Consolidated Omnibus Budget Reconc Act (COBRA) For groups over 20 employees, an employee can continue their group coverage for up to 18 months Employee pays the premium Typically administered through a 3 rd party Oregon State Continuation For groups under 20 employees, an employee can continue their group coverage for up to 9 months Employee pays the premium to the employer Portability An individual plan when a group drops coverage

18 18 WHY DO WE NEED REFORM? Cost Unaffordable premiums Very high utilization of emergency room care Preventive services cost prohibitive More than 60% of bankruptcies due to medical costs Health Carriers can deny coverage based on pre-existing conditions Carriers can stop coverage when you are sick

19 19 WHAT HAS CHANGED TODAY? Elimination of lifetime limits Families can cover children up to the age of 26 No cost for preventive care; mammograms, scheduled physicals, women s contraception Elimination of pre-existing condition exclusion for children under the age of 19 (for all in 2014) Required docs such as Summary of Benefits and Coverage (SBC) and Summary Plan Desc (SPD)

20 20 CHANGES IN 2014 AND BEYOND The train has left the station, but they are still laying the tracks Health Care Exchange Cover Oregon will open 10/1/2013; The exchange is open to individuals and small businesses with less than 50 employees Individuals may receive a subsidy Employers can contribute set dollar amount and employees choose

21 21 INDIVIDUAL MANDATE All individuals required to buy insurance or pay penalty $ $ $695 If a person gets hurt and goes to emergency room, can they buy insurance before being seen because there is no longer a pre-existing condition exclusion?

22 22 EMPLOYER MANDATE All businesses with 50 or more FTEs offer a basic level or pay $2,000/employee (minus 30). If one employee goes to exchange and receives subsidy, $3,000 per subsidized (or whichever is less) Employers will be required to offer a minimum level of benefits to 95% of employees; cost cannot be more than 9.5% of their income Determining FTE all PT employees averaged hours over 30. What is the basic bronze level of benefits?

23 23 COORDINATED CARE ORGANIZATIONS (CCO S) A network of providers (medical, dental, mental health) working together to serve members under the Oregon Health Plan (OHP/Medicaid) Focus on prevention Chronic illness management One budget and accountable for health outcomes 15 in Oregon Projected $11 billion in savings over 10 years

24 24 ACCOUNTABLE CARE ORGANIZATIONS (ACO S) A network of providers (medical providers and hospitals) who come together voluntarily to give coordinated care to Medicare patients Focus on prevention Chronic illness management Avoids duplication of services Shares in the savings of the Medicare program when delivering care and reducing costs together

25 25 LEGACY HEALTH MEDICAL HOME Primary care practice focused on the health of the whole person in all stages of life One physician leads a team that collective takes responsibility for patient s care and communicates to family no specialist in isolation Started in 2007 with a strong move in 2013 to all facilities Current with lab and immunizations Fewer emergency visits Few hospital stays

26 26

27 27 BE A SMART CONSUMER Oregon Prescription Drug Program (OPDP) Get to know your doctors Use in network benefits as much as possible Inquire about the costs in advance Save money by using generics Use urgent care instead of emergency room Preventive care schedule your no cost visit Healthcarebluebook.com know the cost

28 28 THANK YOU Group Insurance PDX Tracy Vicario

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