Exclusive Group Health Insurance Program

Transcription

1 Exclusive Group Health Insurance Program Prepared for: Presented By: Fred Garfield, Senior Vice President Horton Benefit Solutions / Phone: Creating Through Partnership a Solution for Sustainable and Affordable Health Insurance for GAWDA Membership Kenneth Tidwell / Tony Hopkins Horton Risk Advisory Solutions GAWDA Property and Casualty Program kenneth.tidwell@thehortongroup.com / Phone:

2 Executive Summary On behalf of Horton, we are pleased to announce and offer an exclusive association sponsored group health insurance program for GAWDA member firms and their employees. This program is sponsored and administered by The Horton Group, who have successfully provided specialized property and casualty products and services for more than a decade; United Healthcare, the largest nationally recognized leader in health insurance and personal health risk management solutions, is the provider and network sponsor; PlanSourceOne Private Exchange Platform - This use of state-of-the-art technology will expedite and simply the member experience, enrollment and eligibility administration, and HR related processes around managing your group insurance needs. Our objective is this: Provide GAWDA member firms with a long-term sustainable and affordable solution to health insurance and affordable care for their employees. Through this program member firms can take back control of healthcare costs that are rapidly increasing due to ACA regulations, state small group health reform, and fully insured marketplaces that do not recognize value and credible experience. It is our hope that in the following pages, we can demonstrate to GAWDA member firms that beyond a reasonable doubt, Horton has the expertise in your industry; ability to bring new ideas to help you continue to build an industry leading employee benefits program; and the passion to faithfully execute our service plan on your behalf. We appreciate your consideration and hope to have the opportunity to partner with you. Sincerely, Fred Garfield Senior Vice President Horton Employee Benefit Solutions Kenneth Tidwell Vice President Horton Risk Advisory Solutions Challenge/Opportunity Health Insurance Reform Small Group Health Reform Competitive Solutions Full Compliance with Health Care Reform Proposed Strategies Provide competitive solutions that comply with the ACA law Eliminate small group benefit limitations Take control of costs using a long-term sustainable solution based on experience Provide multiple medical options, along with competitive dental and vision Assure guaranteed issue coverage Assure competitive regional rates Provide required ACA reporting and compliance using technology Page 2

3 How will this association program benefit my firm? Beginning 1/1/2016, all small employers of lives offering health insurance will be subject to ACA small group health reform requirements and looking at significant rate increases! - Age-based community rating and risk pooling - Reduced benefits and increased out of pocket costs to members - Skinny networks and limitations to access for care All small group health costs are pooled which means you have no control over your costs. Aggregation removes the insurance company risk sharing found in small group cost pooling, and replaces it with a broader association level actual claims experience rating process. Only the largest claims are pooled, with normal experience recognized for pricing. We can lower renewal trend and provide participating GAWDA member firms and their employee s long-term sustainable and affordable coverage options. This provides GAWDA an opportunity to benefit from the same techniques available to only the largest employers. Existing Aggregation Renewal Trend Example (11 firms, 675 covered employees) % % % % % % Year 0 Year 1 Year 2 Year 3 Old Market Association Market Page 3

4 GAWDA Health Insurance Program Medical Options Medical Benefit Options PPO 1 PPO 2 PPO 3 HSA 1 HSA 2 All Non PPO Services Annual Deductible $1,000 $2,000 $3,500 $2,600 $5,000 $5,000 Family Deductible 2x 2x 2x 2x 2x 2x after Deductible 80% 80% 80% 80% 80% 50% Maximum Out of Pocket $4,500 $6,600 $6,600 $6,450 $6,450 $10,000 Family Max Out of Pocket $9,000 $13,200 $13,200 $12,900 $12,900 $20,000 MD Office Visits Wellness/Preventative Pediatric Primary Primary Care Specialist Care $35 $70 $30 $60 $35 $70 N/A Emergency Room Urgent Care or Retail Clinic Care Prescription Drugs Generic Drugs Preferred Brand Non-Preferred Brand Specialty Brand PPO Network $250 copay, then 80% $250 copay, then 80% $250 copay, then 80% $75 $100 $75 $10 $40 $75 $125 After the deductible After the deductible $10 $40 $75 $125 $10 $40 $75 $125 $10 $30 $60 $60 $10 $30 $60 $60 United Healthcare Choice Plus National PPO Network Varies See Benefit Summary See Benefit Summary Page 4

5 GAWDA Health Insurance Program Dental and Vision Dental Benefits In PPO Non-PPO Annual Deductible $50, 3x for family $50, 3x for family Preventative Care Waived for preventative care 100% - no deductible Two cleanings per year Bitewing X-Rays as required Fluoride Treatments for Children Sealants and Space Maintainers 100% - no deductible Two cleanings per year Bitewing X-Rays as required Flouride Treatments for Children Sealants and Space Maintainers Basic Care - Extractions, Oral Surgery, Restorations, 80% after deductible 80% after deductible Endodontics, and Periodontics Major Care Inlays, Caps, Crowns, Bridges and Dentures 50% after deductible 50% after deductible Annual Benefit Maximum $1,500 per person $1,500 per person Orthodontics Children to 19 50% to $1,000 50% to $1,000 PPO Network United Healthcare Options Dental PPO 90 th Percentile of Usual and Customary Charges Vision Benefits In PPO Non-PPO Eye Exam Annual $10 Co-Pay Up to $40 allowance Materials Lenses, Frames or Contact Lenses $25 Co-Pay See Below Lenses Annual 100% after co-pay Up to $40-$80 based on complexity Lens Coatings Standard Scratch Resistant Other coatings 20-60% off Frames Every 24 months 100% after copay up to $130 retail value 30% discount on overage Contact Lenses Annual Laser Vision Correction Network Elective up to 4 boxes Necessary 100% 15% discount in Laser Vision Network of America Up to $45 allowance Elective up to $105 Necessary up to $210 United Healthcare Primary Plan Network Page 5

6 Premium through June 30, 2016: Revised discounted rates shown below are monthly based on family coverage tier, and will be based on the group age/sex demographics and geographical cost of care factors: PPO 1 Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Single $ $ $ $ $ $ $ $ $ EE + SP $ $ $ $1, $1, $1, $1, $1, $1, EE + CH $ $ $ $ $ $ $1, $1, $1, Family $1, $1, $1, $1, $1, $1, $1, $2, $2, PPO 2 Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Single $ $ $ $ $ $ $ $ $ EE + SP $ $ $ $ $1, $1, $1, $1, $1, EE + CH $ $ $ $ $ $ $ $1, $1, Family $ $1, $1, $1, $1, $1, $1, $1, $2, PPO 3 Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Single $ $ $ $ $ $ $ $ $ EE + SP $ $ $ $ $ $1, $1, $1, $1, EE + CH $ $ $ $ $ $ $ $1, $1, Family $ $1, $1, $1, $1, $1, $1, $1, $2, HSA 1 Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Single $ $ $ $ $ $ $ $ $ EE + SP $ $ $ $ $ $ $ $1, $1, EE + CH $ $ $ $ $ $ $ $ $1, Family $ $1, $1, $1, $1, $1, $1, $1, $1, HSA 2 Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Single $ $ $ $ $ $ $ $ $ EE + SP $ $ $ $ $ $ $ $1, $1, EE + CH $ $ $ $ $ $ $ $ $1, Family $ $ $ $1, $1, $1, $1, $1, $1, All rates shown above include $16.00 per employee per month for plan administration, enrollment processing, and technology access fees. Page 6

7 Dental rates shown below are monthly and are based on geographical cost of care factors. Vision rates shown below are monthly and do not vary by census or geographical location: Single Employee Single + Spouse Single + Children Single + Family Dental Region 1 Dental Region 2 Dental Region 3 Dental Region 4 Dental Region 5 Dental Region 6 Vision All Regions $26.37 $31.26 $36.10 $42.20 $46.88 $52.35 $5.72 $52.74 $62.51 $72.20 $84.39 $93.77 $ $10.84 $56.33 $66.76 $77.11 $90.13 $ $ $12.72 $86.70 $ $ $ $ $ $17.89 Page 7

8 For Obtaining an Offer of Coverage STAGE 1: Interested firms will submit a completed and signed UHC employer application form with all supporting documentation requested Can be completed by phone with Horton Group representatives All highlighted questions on the form must be answered Employers must provide the following: a census of eligible full-time employees containing likely dependent coverage elections and additional required information by Excel spreadsheet A copy of your most recent medical premium bill from your current health insurance carrier A copy of a Summary of Benefits for all medical plans currently offered to your employees All information should be ed to The Horton Group: toi.logan@thehortongroup.com / call for questions Upon receipt and review by United Healthcare, a firm rate offer will be provided to you within 5 business days STAGE 2: Upon Receipt of a Firm Rate Offer If the rate offer is competitive and acceptable, a final signed acceptance letter and the estimated first month s medical premium payment must be received by The Horton Group. Check is to be made payable to United Healthcare in the amount designated as deposit premium payment (equal to the number of employees times the single employee rate for the lowest cost option) Any census and enrollment adjustments from the actual final enrollment will be made to a following monthly bill Overnight the letter and check to: The Horton Group Attn: Fred Garfield / GAWDA Orland Parkway Orland Park, IL Page 8

9 STAGE 3: Once the items required in Stage 2 are received, all eligible employees will need to complete their final enrollment information and provide benefit plan selections All Groups under 25 lives will complete paper applications. Forms will be provided for obtaining coverage elections or waivers Forms are to be returned by overnight mailto The Horton Group before the deadline date below Groups over 25 lives will enroll on the PlanSourceOne website. Each employee will initially log into the site and establish their unique login and password They will provide all required and necessary information that is not provided on the census file, such as their home address, current phone numbers, dependent names, dependent social security numbers, and dependent dates of birth They will elect or waive each of the health coverages offered to them They will electronically sign for their enrollment choices They will be able to print or receive by a verification statement Enrollments must be completed by the 20 th for an effective date the first of the following month Please expect calendar days processing time prior to any requested effective date based on completing all the above steps in a timely manner. IMPORTANT REQUEST: HIGH MEMBER FIRM PARTICIPATION AND ENROLLMENT IS OUR BEST GUARANTEE TO ASSURE THE PROGRAM S LONG TERM SUCCESS! Page 9

10 General Rules and Program By-Laws: 1. Associate member firms that wish to participate in the group insurance program offered by GAWDA must be and remain current as an active member of the association in good standing and current with all dues, expenses, or any capital contributions. 2. The group insurance program will offer the following benefits to its members, all of which qualify for pre-tax employee contributions: a. Five ACA qualifying PPO medical and pharmacy benefit insurance programs; i. There will be three PPO traditional first-dollar copayment options; ii. There will be two PPO health savings qualified HDHP options; iii. These plans will all have deductible and out of pocket limits that comply with the ACA regulations and prevailing member cost limitations; iv. These plans will not be subject to any medical underwriting or pre-existing condition limitations; v. These plans will not have any lifetime major medical expense limitation; vi. There will be an annual open enrollment offered in June for a July 1 st effective date. b. Voluntary dental insurance; c. Voluntary vision insurance. 3. The member firm must agree to the following stipulations and requirements of participation in the health insurance program: a. The member firm must agree to comply with all Applicable Large Employer requirements as stated under the Affordable Care Act of 2010, as amended, subject to all regulatory guidance offered; i. The member firm must offer coverage to all full time salaried (exempt) and hourly employees working 30 hours per week or more; ii. The member firm agrees that they will offer each and every health insurance coverage within the program on a pre-tax basis to its full-time employees and eligible dependents; 1. For those employees who are age 65 or over, and who are either electing single coverage or who are electing employee + spouse where the spouse is also age 65 or over, we ask member employers to direct these members to Medicare and provide a compensation subsidy equal to - but not to exceed - the employer share of any health insurance costs as an offset to Medicare Part-B and supplemental medical and pharmacy coverage costs. 2. Exceptions to Medicare will be granted to employees who: a. Have covered spouses under the age of 63½, or b. Have covered dependent children under the age of 26 i. Note children may have less expensive individual options available on the state exchange in which they reside Page 10

11 iii. The member firm must agree to offer coverage subject to ACA affordability requirements that the lowest cost offered program cost less than 9.56% of the W-2 income (2015 limitation) of their lowest paid full-time qualifying employee; iv. The member firm will receive reporting and recordkeeping benefits from the program, including issuance of all necessary IRS reporting forms for employees to show they have ACA qualifying coverage, however they remain responsible for any and all additional employer reporting requirements; v. That they will enroll in a timely manner (no more than 30 calendar days from hire) every qualifying employee on the technology platform used by the program so elections and qualified waivers can be recorded; vi. That they will terminate coverage in a timely manner (no more than 3 business days) any employee who is no longer eligible for coverage so proper COBRA notifications can be sent; b. The member firm agrees to pull, review, and remit payment on premium statements no later than the 5 th day of the month in which coverage is provided; 4. The member firm acknowledges that there will be a penalty assessed should they choose to join the program, but then terminate at their own discretion participation in the program, at any time during the first three years of participation: a. If a member firm terminates coverage between the first day and the last day of the thirty-sixth month of participation, a one-month premium penalty will be assessed by the association; b. Tracking of participation dates for member firms will begin on the first day in which coverage is made effective for its employees; c. The penalty assessed will be the average monthly total premium amount paid by the member firm for health coverage on covered employees during their period of participation in the program. d. Exemptions for this penalty apply only to the bankruptcy and cessation of business operations, or the sale of 100% of a member firm to an unrelated party. Replacement of coverage with another insurance carrier, sale of the company, or any other dissolution of participation will not be considered an exemption from penalty. 5. To assure this program remains cost effective for its participating firm members, it is not structured for or able to pay any compensation to outside brokers. It is at the sole discretion of any member firm if they wish to retain additional services from any broker outside of the structure, fees and costs, and insurance premiums paid as part of this program. Page 11

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