Benefits Basics UBCM 2013 Benefits Conference. Pacific Blue Cross April 18, 2013

Transcription

1 Benefits Basics UBCM 2013 Benefits Conference Pacific Blue Cross April 18, 2013

2 Agenda What are Employee Benefit Plans? Common Questions and Processes Tips When Negotiating Benefits Administration Basics PBC Online Applications Questions?

3 Your Team Name Phone Scott Holmes Account Manager, Group Client Development Annie Ni Customer Service Rep, Group Client Development Paul Stephens Manager, Group Client Development

4 About Pacific Blue Cross BC Based Not- for-profit Exceptional Customer Service Technology Robust claims management Our local service team and decision-makers allow us to respond to you quickly Local customer service and claims centres mean employees deal with people who understand local healthcare environment and issues. Our decisions are not driven by shareholder interests. Your interests are first and foremost. Fast and accurate claims payments. Friendly and knowledgeable staff to answer questions. Quick response to inquiries and issues. State-of-the-art self service site makes accessing information easy. Online enrollment system puts you in charge of your plan administration. Comprehensive plan reporting available online. System checks and balances ensure appropriate claims are manually reviewed, others go through automated adjudication rules (Health and Dental only, LTD claims are all manually reviewed). Employees receive the benefits you have provided. You don t pay for expenses that aren t covered.

5 What are Employee Benefit Plans?

6 Overview of Benefit Plans - What is an Employee Benefit Plan? Financial protection for some event occurring in a typical individual s life that could cause significant hardship or stress for them and their family, such as: Not being able to work Death of individual or family member Retirement Being diagnosed with a severe condition Being injured in an accident Employer group plans will meet many needs for many employees They will not meet everyone s needs in every scenario

7 Overview of Benefit Plans Why Have a Benefit Plan? Attraction and retention Competitive practice Meet employee demand Union collective agreement Group vs. individual buying power Typically no medical requirements for eligibility Good corporate citizen

8 Overview of Benefit Plans Why Participate in UBCM s Plan? Group buying power Leverage better insurance prices Pooled financial underwriting to protect against fluctuations in costs Small group limitations on design, administration and claims are not applied Access to services and assistance through UBCM, and PBC Booklets, research Assistance with negotiations etc.

9 Benefits Cost Drivers What benefits are provided How much coverage (plan design) How much is used (claims experience) Demographics of the group (age, gender, occupation) Market trends (drug costs, dentists charges) Changes in public programs (Pharmacare, MSP) Economy Provider charges 9

10 Death Benefits Overview Group Benefit Comments Life Insurance AD&D Typically a function of annual earnings or a flat amount Basic coverage offered while higher levels may require medical review before approved Pays if death, serious dismemberment or paralysis Often set equal to life insurance amount Some plans also cover spouse and dependents Dependent Life Smaller flat amount of coverage for spouse and or dependent children with no medical approval required Optional Life Member paid, available for member and spouse, medical review required before approval. Rates based on gender, age and smoker status Optional AD&D Member paid, available for member and family with no medical approval required 10

11 Disability Benefits Overview Group Benefit Short Term Disability Long Term Disability Comments Pay percent of weekly pay to maximum; or flat benefit Very different from sick leave as benefits approved only after medical review Elimination period before benefits start Benefits to maximum duration Pay percent of monthly pay to maximum; or flat benefit Benefits approved / ongoing with medical review Elimination period before benefits start Benefits to a maximum duration Integrated with CPP disability May have inflation indexing Key clauses include: Definition of disability; pre-existing conditions ; exclusions 11

12 Extended Health Care (EHC) Expenses not covered by provincial Medicare Covers individual and direct family members What does it typically cover? (you can choose) Prescription drugs Vision care: coverage for lenses, frames and contacts Can also include eye exams or laser eye surgery Typically subject to fixed dollar maximum every 2 yrs Paramedical services: chiropractors, massage therapists, physiotherapists, acupuncture, naturopaths, podiatrists Hospital: private/semi-private room Ambulance Medical services/equipment: hospital beds, wheel chairs, foot orthotics, hearing aids Out of country emergency medical expenses: physicians, surgeons, hospitals, drugs

13 Percentage Paid by Plan in UBCM s Plan 12 Months Ending March 2012

14 Percentage Paid by Paramedical in UBCM s Plan 12 Months Ending March 2012

15 Dental Care Three types of expenses Plan A - basic (preventive/minor restorative) Plan B - major restorative Plan C - orthodontics Components could include deductible co-insurance dollar maximum service limits (i.e. - units of scaling; frequency of visits)

16 Percentage Paid by Plan in UBCM s Plan 12 Months Ending March 2012

17 Health Spending Account (HSA) Employer-paid account HSA is not taxable income to the employee (except in Quebec) Governed by CRA rules Broad definition of eligible expenses and eligible dependents Insurer typically administers the HSA and pays claims

18 Common Questions and Processes

19 Common Questions In Group Benefits What is Volume? Amount of coverage each employee has. What is an NEM or NEL (Non Evidence Maximum)? The maximum amount of coverage after which a medical questionnaire/review is required. What is a Trend? The percentage applied to rates determining overall market behavior. Used in absence of full credibility, based on PBC s entire block of business. What is Credibility? The percentage that group usage reflects the actual group trend.

20 What is Experience? Benefit usage (claims total) for the past year (and beyond). Premium In versus Claims out. Can Employees Waive Coverage? Generally no. What s good for the group is good for the individual (or vice versa) HOWEVER there are exceptions which will be addressed later by Annie.

21 How Does the Math Work? Rate(Volume)/unit factor = Monthly Premium Cost Unit factors differ per product line STD unit factor of 10 LTD unit factor of 100 Life/ADD unit factor of 1000 Example 1 Life: Contract states flat 25,000 benefit for Life if rate is $0.25 (25k is your volume) $0.25 x (25,000) / 1000 = $ 6.25 is the cost/ month

22 Example 2 LTD: Contract states 66.67% of pre-disability earnings. Annual salary is $35, K/12mo s = $ (66.67%)= $ (this is your volume) $1.78 x / 100 = $34.61/month is the premium cost

23 Rate Setting Components Simple Example Paid Claims + Larger groups are more influenced by their own components, smaller groups influenced by components of all groups in the UBCM pool Adjustment for reserves and interest + Inflation/Trend + Expenses Paid premium = Change in renewal rates

24 Tips When Negotiating Benefits

25 Tips When Negotiating Benefits Each municipality is the policyholder of its contracts You may request contract amendments Changes must be approved by PBC / BC Life and quote provided They must fit within the UBCM plan underwriting guidelines Must also meet the legal and tax requirements governing benefit plans Not all changes are possible Check with PBC / BC Life or UBCM when in negotiations for costs and feasibility before agreeing to changes Process can sometimes be ongoing with various approaches discussed and priced Every change can affect rate. It doesn t matter how small it seems, every modification to your plan may have an effect on rate.

26 Removing benefits doesn t necessarily reduce rates. Removing unused benefits won t reduce rates as there has been no experience and therefore no pressure on rates. If one group has a benefit another will want it. No group wants to feel they re being denied something, often over very small amounts. How much time do I have? Expect it will take at least 24 hours to review and receive a response on benefit plan changes. Can I expect further negotiations? If you can anticipate further quote requirements, send them with the initial request. For instance if $200/massage benefit is being negotiated, ask for alternates assist with the negotiation and speed the process.

27 Administration Basics

28 Plan Administration Basics Employee Eligibility Waiver of Group Benefits Late Applicants Waive Waiting Period Extension of Coverage Plan Administrator Website

29 Who is eligible? Definition of employee Min. # of hours (ie. 20 hrs/week) Completed the Waiting period Be actively at work on eligibility date Retirees, casual, seasonal employees typically not eligible Review definitions of eligibility requirements and waiting period

30 When are employees eligible? Eligibility First Day at Work Waiting Period Eligibility Date The day the employee completes the waiting period February 2 3 months May 2 The first day of the month following the month in which the waiting period is completed February 2 3 months June 1

31 When to enroll? First become eligible and complete waiting period Initial hire: complete Application for Group Benefits Submit it once waiting period completed Avoid late applicant limitations

32 Can employees waive benefits? Compulsory plan (100% participation required) Yes, if covered under another plan Complete Waiver of Group Benefits If other coverage terminates, enroll without late applicant limitations (within time limit) Non-compulsory plans Yes (fill out back of enrollment form) Statement of Health required if joining later Employee pays cost of any medical reports May be denied

33 Application for Group Benefits form

34 What is a late applicant? Past allowable enrolment period Waived benefits before, now applying while other coverage still active Check contract/policy for any late app restrictions $250/person max dental coverage (12 mos.) Statement of Health

35 Waive Waiting Periods Generally only for key personnel Example: transfer from another municipality All or nothing Complete Request to Waive Waiting Period

36 Extension of Coverage PBC will review each on case by case basis Illness or injury As long as employee is not terminated Premiums are paid Establish policy for how long, apply to all EI compassionate care leave As long as employee is not terminated Premiums are paid If disabled while on EI care leave, payable after EI

37 Extension of Coverage Temp lay-off or unpaid leave of absence Expect employee to return to work Up to 90 days for disability benefits Up to 180 days for all other benefits Strike or indefinite lay-off All benefits (except disability) can extend up to 6 months Disability terminate on last day of work unless negotiated Pay in lieu of notice termination & severance pkg In accordance with gov t legislation (BC: 1 week/yr of service) up to max 8 weeks Beyond above, except disability, can cont. 1 month/yr of service (max 6 months)

38 Plan Administrator Website Forms and supplies PBC Admin Guide Look up plan benefits

39 Web Access For Members 24 hr secure self-service Plan information Claims information E-Claims Forms / Direct deposit inquiries My Good Health 39

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41 CARESnet Home Page 41

42 CARESnet Mobile App For your iphone or another ios device (ipad) Available on Apple AppStore

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44 Contact Us For employees: General Inquiries: Extended Health Claims: Dental Claims: Toll Free: For employers Enrollment, changes, terminations Changes to your group plan Group billing STD, LTD and life claims

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