1 Self Funded Health Insurance To be or not to be? Janet S. Spencer A.S.A, M.A.A.A., C.P.A.
2 Self Funded Insurance To be or not to be? BlueCross BlueShield of SC (BCBSSC) Self Funded To be or not to be? Important Self Funded Group Issues Stop Loss Coverage Actuarial Management of Self Funded Groups
3 BlueCross BlueShield of SC A. M. Best Rating: A+, no subs <A Sustained and profitable revenue growth Long-term success in every market segment Low administrative cost position through diversification 12,000 employees
4 Diversification - Private Sector Business Major Group Division Insured and ASO Group and Individual Division - Small Group, Individual Products, State Health Plan, FEP National Alliance Division Medicare Advantage / PDPs Two Independent TPAs HMO Property and Casualty Life Insurance
5 Diversification Government Programs Administration Medicare TRICARE Medicaid Medicare Data Center
6 BCBSSC Major Group Division* Includes employer groups with 50+ employees Self funded ASO with or without stop-loss Does not include: Alliance accounts State Plan and Federal Employee Plan administration Medicare, TRICARE, and Medicaid Plan administration All other in-source processing
7 BCBSSC Major Group Division* - Percentage of Accounts 100% 90% Percent of accounts 80% 70% 60% 50% 40% 30% 20% Self Funded Insured 10% 0%
8 Self Funded Health Insurance To be or not to be? When should a group self fund health insurance? When will a group self fund health insurance?
9 When should a group self fund health insurance? When the financial risk has been assessed through the use of risk simulator models, including the application of various stop loss provisions And, when the group has the required financial risk tolerance
10 When should a group self fund health insurance? Financial Risk Tolerance Long term financial viability industry, economic factors Strong cash/ working capital position Financial and risk management expertise to manage the increased complexity and fiduciary responsibility
11 When will a group self fund health insurance? When the group decision makers believe that self funding will cost less Reduced claims cost Reduced administrative fees More control over benefit design and processing services Reduced insurance carrier risk and profit margins
12 When will a group self fund health insurance? Reduced Claims Cost Group decision makers want to bear their own cost and not be pooled, believing that their participants will have better experience than the pool. Several years of good experience have still resulted in annual rate increases. Group decision makers believe that carrier claims cost projections are too high because carriers always overstate claims trend.
13 When will a group self fund health insurance? Reduced Administrative fees The group decision makers want increased negotiating power by unbundling services and shopping all price components. Benefit carve outs Administrative pricing components Stop-loss coverage
14 When will a group self fund health insurance? Increased control over benefit plan design and processing components ERISA preemption of insurance product state regulations that include benefit mandates Increased customization beyond carrier underwriting standards Selection from a menu of managed care / disease management services Selection from an array of technology levels for enrollment, billing, and reporting
15 When will a group self fund health insurance? Reduced insurance carrier risk and profit margins
16 Important Self Funded Group Issues The risk of large claims Required financial, legal, and risk management expertise Transition and termination complexity
17 Important Self Funded Group Issues Risk of large claims Stop loss coverage complexity Product design and policy provisions Availability at the group and individual level Potential gaps in coverage Fluctuations in monthly claim payments under the stop loss limit
18 Important Self Funded Group Issues Successful management of increased financial risk and fiduciary responsibilities Financial / accounting Employee benefit expertise Legal / regulatory compliance
19 Important Self Funded Group Issues Finance / Accounting Complex billing of claims / administrative components Cash flow budgeting and monitoring Reserve funding structure general assets or trust ERISA Reporting / IRS Tax Code
20 Important Self Funded Group Issues Self Funded Cost Components Claims reimbursement TPA, PBM, Mental Health Specific and aggregate stop loss applications Administrative fees General administration - pepm Network fees - pepm or shared savings Processing technology fees - pepm
21 Important Self Funded Group Issues Self Funded Cost Components (continued) Managed Care / Disease Management fees pepm or per case - bundled or unbundled Medical Information fees pepm Wellness Programs Specific stop loss premiums Aggregate stop loss premiums Customized reporting fees
22 Important Self Funded Group Issues Employee Benefits Expertise Plan benefit coverage and policy issues Actuarial concepts selection, benefit changes, and reserves Stop loss coverage and policy issues
23 Important Self Funded Group Issues Legal / Regulatory Compliance ERISA disclosures and reporting requirements Compliance with federal mandates and audits TPA and other vendor agreements Stop loss coverage agreements
24 Important Self Funded Group Issues Transition and Termination Complexity Potential coverage gaps in the transition to new TPAs and / or new stop loss carriers Transition back to an insured product Underwriting perception of selection Cash flow bubble for self funded run-out and insured product premium payments
25 Stop Loss Coverage Availability and risks General underwriting guidelines Specific stop loss Aggregate stop loss
26 Stop Loss Coverage A competitive stop loss market provides diversity and flexibility in product design. Risks Gaps in the policy coverage dates Carve out of specific individuals Consistency between the plan coverage and the stop loss policy coverage Long term financial viability of the stop loss carrier
27 Stop Loss Coverage General Underwriting Guidelines Require 200+ employees; participation requirements same as for insured products Demographic and industry rating Evaluation of provider reimbursement contracts and claim outlier provisions Integration of specific and aggregate coverage Financial viability of the self funded group Carve out of specific individuals
28 Stop Loss Coverage BlueCross BlueShield of SC Specific Stop Loss Typical Maximum Limit Guidelines Number of Lives Maximum limit $ 50, , , , $500,000 to unlimited
29 Stop Loss Coverage BlueCross BlueShield of SC Specific Stop Loss Standard Policy Terms Incurred basis 12/12 Incurred with a run-out provision 12/15 Paid basis all claims paid during the policy period, regardless of incurred date Variation Aggregating specific stop loss
30 Stop Loss Coverage BlueCross BlueShield of SC Aggregate Stop Loss Standard Policy Terms Incurred basis 12/12 Incurred with a run-out provision 12/15 Paid basis all claims paid during the policy period, regardless of incurred date Run-in provision with run-in maximum limit
31 Stop Loss Coverage BlueCross BlueShield of SC Aggregate Stop Loss Aggregate Annual Attachment Point Calculation Projected claims for policy period Adjustment for integration of specific stop loss Add corridor of 15%, 20%, or 25%
32 Stop Loss Coverage BlueCross BlueShield of SC Aggregate Stop Loss Attachment Point Application Annual Attachment Point retrospective settlement after the end of policy period Monthly Attachment Points interim limits to reduce cash flow fluctuations; adjustment to annual attachment point after the end of the policy period
33 Stop Loss Coverage BlueCross BlueShield of SC Aggregate Stop Loss Attachment Point Range Minimum Attachment Point - Dollar floor applied after the enrollment adjustment of the annual attachment point Aggregate Reimbursement Maximum
34 Stop Loss Coverage BlueCross BlueShield of SC Aggregate Stop Loss Integration with Specific Stop Loss Standard rule - Aggregate stop loss requires specific stop loss Contractual Variations Implied specific stop loss Tiered risk corridors
35 Actuarial Management of Self Funded Groups Maintain the claims cost projection systems for Underwriting applications Monitor the adequacy of administrative pricing components Monitor the billing of administrative pricing components Monitor the stop loss results and other claims reimbursement gains/losses Provide IBNR estimates and other group specific reporting
36 Self Funded Health Insurance To be or not to be?
Beware of Stop-Loss Coverage Gaps When Choosing a Self-Funded Major Medical Plan Alden J. Bianchi, Esq., Member, Mintz Levin Edward A. Lenz, Esq., Senior Advisor, Mintz Levin February 24, 2015 Mintz Levin.
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