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Self funded health care – a big business advantage

Check out this article from Business Insurance by one of their staff writers. In this article, Business Insurance dives into the awesome advantages of self-funding for big businesses.

You can read the original article here.


Health insurance benefits are expensive. The rising costs of health care has driven up insurance premiums to levels where many businesses have been forced to reduce these benefits or drop them altogether. There is, however another option that is less regulated, taxed less and typically results in cost savings: self funded health insurance. The problem is, it's not always the best option for all employers, particularly the smaller ones. And there's a number of reasons for this:
What is self funded health care a.k.a. self-insurance?

Self-insurance is a method of providing health care to employees by taking on the financial liabilities of the care instead of paying premiums to an insurance agency to do the same. In other words: when a person covered under a self-funded plan needs medical care, the company is financially responsible for paying the medical bill (minus deductibles). It's an alternative risk transfer strategy that assumes the risk and liability of medical bills for those covered instead of outsourcing it to a third party. It's a surprisingly common practice:

In 2008, 55% of workers with health benefits were covered by a self-insured plan….and 89% of workers in firms of 5,000 or more employees.
Most (but not all) self-insurance plans are administered by a third party, usually a health insurance company, in order to process claims. The bills are simply paid for by the employer. Health insurance companies act as a third party administrators in what are called ASO contracts (Administrative Services Only)

Another common component of self insurance plans is stop-loss insurance. This is a separate insurance plan that the employer can purchase to reduce the overall liability of claims. With this type of insurance, if claims exceed a certain dollar amount, stop-loss kicks in paying the rest. There are two kinds of stop-loss insurance:

Specific – covers the excess costs from larger claims made by individuals in the group
Aggregate – kicks in when total claims by the group exceed a set amount

For example, a company who self-insures their $1000 employees projects $100,000 in medical care claims for the year. If they purchase aggregate stop-loss insurance for claims that exceed 120% of the expected amount or $120,000, the insurance will pick up the bill for the remaining claims. If the company purchases specific stop-loss insurance at 200%, if any single claim exceeds $2,000, the stop-loss pays the remainder.

Typically, self-funded insurance providers will purchase both specific and aggregate stop-loss insurance unless the conditions are such that specific stop-loss provides enough financial protection.
Benefits of self-insurance

There are a number of financial and administrative advantages to using self-funded health insurance plans for employers. According to the Self-Insurance Institute of America (SIIA) these include:

  • The employer can customize the plan to meet the specific health care needs of its workforce, as opposed to purchasing a 'one-size-fits-all' insurance policy.
  • The employer maintains control over the health plan reserves, enabling maximization of interest income – income that would be otherwise generated by an insurance carrier through the investment of premium dollars.
  • The employer does not have to pre-pay for coverage, thereby providing for improved cash flow.
  • The employer is not subject to conflicting state health insurance regulations/benefit mandates, as self-insured health plans are regulated under federal law (ERISA).
  • The employer is not subject to state health insurance premium taxes, which are generally 2-3 percent of the premium's dollar value.
  • The employer is free to contract with the providers or provider network best suited to meet the health care needs of its employees.

There are, however, some drawbacks to self-insurance policies:

Health care can be costly, so heavy claims years can be extremely expensive
Self insurance isn't tax deductible the same way the costs of providing health insurance is.
Financial benefits are long-term, particularly with an investment component.
Small businesses at a disadvantage

Self insurance is much more prevalent for larger companies mostly because it is easier to predict health care costs from a larger group. The more people in the group, the less potentially damaging a single expensive claim will be to the plan overall. That's why less than 10% of companies with less than 50 employees use self-insurance.

Because risk is more difficult to predict with smaller groups, stop-loss insurance is also more expensive for smaller businesses. The practice of “lasering”, or increasing deductibles for specific higher risk employees can also be much tougher on small firms. As a result, self-insurance tends to be a less cost effective option than it is for larger companies.

Another roadblock for small businesses is a lack of cash-flow that is necessary to finance self-insurance. This doesn't mean, however, that small businesses can't benefit from a self-insurance plan. In fact, an increasing number of small businesses still are. But fully understanding the risks and rewards for doing so can sometimes be difficult.
Regulations

Because the only 3rd party administration of insurance (stop-loss) is between the employer and the insurance company directly, it is not subject to state level regulation the way traditional insurance policies are. Instead, they're regulated by the department of labor under the Employee Retirement Income Security Act – ERISA. Benefit administrators must still comply with federal standards despite the lack of state regulation.

California SB 1431

California is considering a proposed legislation to regulate the sale of stop-loss policies to smaller businesses. On the surface, the regulation looks as though it is an attempt to prevent small businesses from taking on too much risk. But the true intentions of the legislation may be to prevent cherry-picking of generally healthier small businesses (effectively removing them from the health insurance pool). This cherry-picking would theoretically cause traditional insurance premiums to become more expensive.

According to the SIIA, SB 1431 would prohibit the sale of stop-loss policies to employers with fewer than 50 employees that does any of the following:

  • Contains a specific attachment point that is lower than $95,000;
  • Contains an aggregate attachment point that is lower than the greater of one of the following:
    • $19,000 times the total number of covered employees and dependents;
    • 120% of expected claims;
    • $95,000

This legislation would effectively limit the options of small businesses as it would force them to purchase a more expensive low deductible stop-loss policies. And according to the SIIA, with this legislation, almost no small business under 50 employees would (nor should they) consider self-insurance as an option.

If the legislation is passed in California, it has been suggested that it is only time before other states follow suit and/or enact even stricter regulations on small businesses. The SIIA even has a facebook page dedicated to defeating the bill they say is:

“…unnecessary and will only exasperate the problem that small employers in California face in being able to afford the rising cost of providing quality health benefits to their employees.”

So while self insurance can be a relatively risky option for small businesses, with legislation like this, it could no longer be a realistic option at all… And, in effect: another competitive advantage big businesses will have over their smaller counterparts.

You can read the original article here.

Source:

Staff Writer. (Date Unlisted). "Self funded health care – a big business advantage" [Web Blog Post]. Retrieved from address http://www.businessinsurance.org/self-funded-health-care-a-big-business-advantage/


doctor and patient

Self-funding and Voluntary Benefits: The Dynamic Insurance Duo

Did you know that self-funded health insurance and voluntary benefits can be a dream team when used in conjunction with each other? Check out this great article by Steve Horvath and Dan Johnson from Benefits Pro and find out how you can make the most of this dynamic insurance duo.

In an era of health care reform, double-digit rising health care costs, and plenty of “unknowns,” many employers view their benefit plans as a challenging blend of cost containment strategies and employee retention.

But perhaps they need to better understand the value of a little caped crusader named voluntary benefits.

Employers of all sizes share common goals when it comes to their benefits. They seek affordable, and quality benefits for their employees.

Some companies achieve these goals by cutting costs and going with a high-deductible, self-funded approach. While many associate self-funding with larger employers, in the current marketplace, it has become a viable option for companies across the board.

Especially when paired with a voluntary benefits offering supported by one-on-one communication or a call center, employers are able to cut costs and offer additional insurance options tailored to their employees’ needs. But there’s more.

Voluntary enrollments can help employers meet many different challenges, all of which tie back to cost-containment, streamlined processes and employee understanding and engagement. But before we explore solutions, let’s first understand why so many employers are going the self-funded route.

For most large and small employers, the costs of providing health care to employees and their families are significant and rising.

For companies who may be tight on money and are seeing their fully-insured premiums increase every year with little justification, self-funding serves as a great solution to keep their medical expenses down.

Self-funding: An overview

Self-funding allows employers to:

  1. Control health plan costs with pre-determined claims funding amounts to a medical plan account, without paying the profit margin of the insurance company.
  2. Protect their plan from catastrophic claims with stop-loss insurance that helps to pay for claims that exceed the amount set by their self-funded plan.
  3. Pay for medical claims the plan actually incurs, not the margin a fully insured plan underwrites into their premium, while protecting the plan with catastrophic loss coverage when large expenses are incurred. Plans may offer to share favorable savings with their employees through programs like premium holidays. These programs allow employee contributions to be waived for a period of time selected by the employer to reward employees for low utilization and adequate funding of their claims accounts and reserves.
  4. Take advantage of current and future year plan management guidance.
  5. Save on plan costs by using predictive analysis for health and wellness offered by the third-party administrator (TPA).

Beyond these advantages,self-funded plans may not be subject to all of the Affordable Care Act regulations as fully-insured plans, which is one of the reasons they provide a solution for controlling costs. Without these requirements, the plans can be tailored much more precisely to meet the needs of a specific employee group.

Boosting value: Advantages of adding voluntary benefits to a self-funded plan

Based on an employer’s specific benefit plan, and what it offers, employers are able to select voluntary benefits that can complement the plan and properly meet employees’ needs without adding extra costs to the plan.

Employees are then able to customize their own, personal benefit options even further based on their unique needs and available voluntary benefits.

This provides employees a myriad of benefits while also allowing them to account for out-of-pocket costs due to high-deductibles or plan changes, as well as provide long-term protection if the product is portable.

Voluntary solutions are about more than the products

Aside from the common falsehood that voluntary benefits are only about adding ‘gap fillers’ to your plan, you may be pleasantly surprised to learn that conducting a voluntary benefits enrollment can actually offer a number of services, solutions, and products, many of which may be currently unfamiliar to you.

Finding, and funding, a ben-admin solution

Some carriers offer the added bonus of helping employers install a benefits administration system in return for conducting a one-on-one or mandatory call center voluntary benefits enrollment.

The right benefits administration systems can help remove manual processes and allow HR to do what they do best—focus on employees and improving employee programs. No more headaches around changing coverage, change files to carriers, changing payroll-deductions or premiums.

Finding the benefits administration system that works best for your situation can make a big difference for your HR team.

Communication and engagement

Many employees are frustrated and scared about how changes to the insurance landscape will impact them. And with a recent survey noting that 95 percent of employees need someone to talk to for benefits information,they clearly are seeking ongoing communications and resources.

During the enrollment process, some carriers work with enrollment and communications companies who understand the employees’ benefit plan options and help guide them to the offerings that are best for them and their families.

At the same time, employers can enhance the communication and engagement efforts on other important corporate initiatives. For example, a client of ours increased employee participation in their high-deductible health plan (HDHP) via pre-communication.

Of the 90 percent of employees that went to the enrollment, nearly 70 percent said they were either likely or very likely to select the HDHP. Just a little bit of communication can go a long way toward employee understanding.

Providing education and engagement about both benefits and workplace initiatives increases the effectiveness of these programs and contributes to keeping costs down for employers. The more engagement employers generate, the healthier and better protected the employees.

Prioritizing health and wellness

Employers can also use the enrollment time with employees to remind them to get their annual exams. Many voluntary plans offer a wellness benefit (e.g. $50 or $100) to incentivize the employee and dependents.

The ROI for an employer’s health plan provides value as regular screenings can help detect health issues in the beginning stages so that proper health care management can begin and medical spend can be minimized.

Employers have also seized the opportunity of a benefits enrollment to implement a full-scale wellness program at reduced costs by aligning it with a voluntary benefits enrollment.

An effective wellness program will approach employee health from a whole-person view, recognizing its physical, social, emotional, financial and environmental dimensions. A properly implemented wellness program can ultimately make healthy actions possible for more of an employee population.

A formidable combination

What employers are seeking is simple -- quality benefits and a way to lower costs. With that in mind, offering a self-funded plan with complementary voluntary benefit products and solutions allows employers to take advantage of multiple opportunities while, at the same time, providing more options for their employees.

In today’s constantly changing landscape, self-funded plans paired with voluntary benefits is a formidable combination – a dynamic insurance duo.

See the original article Here.

Source:

Horvath S., Johnson D.  (2016 November 23). Self-funding and voluntary benefits: the dynamic insurance duo [Web blog post]. Retrieved from address http://www.benefitspro.com/2016/11/23/self-funding-and-voluntary-benefits-the-dynamic-in?page_all=1


5 Crucial Wellness Strategies for Self-Funded Companies

In the article below from Care ATC, you will learn the importance of health care coverage - self-funded or not - and how to leverage different programs to the benefit of your company and its employees. Explore these five strategies for self-insured companies and find what will work best for you.

You can read the original article here.

Instead of paying pricy premiums to insurers, self-insured companies pay claims filed by employees and health care providers directly and assume most of the financial risk of providing health benefits to employees. To mitigate significant losses, self-funded companies often sign up for a special “stop loss” insurance, hedging against very large or unexpected claims. The result? A stronger position to stabilize health care costs in the long-term. No wonder self-funded plans are on the rise with nearly 81% of employees at large companies covered.

Despite the rise in self-insured companies, employers are uncertain as to whether they’ll even be able to afford coverage in the long-term given ACA regulations. Now more than ever, employers (self-insured or not) must understand that wellness is a business strategy. High-performing companies are able to manage costs by implementing the most effective tactics for improving workforce health.

Here are five wellness strategies for self-insured companies:

Strategy 1: Focus on Disease Management Programs

Corporate wellness offerings generally consist of two types of programs: lifestyle management and disease management. The first focuses on employees with health risks, like smoking or obesity, and supports them in reducing those risks to ultimately prevent the development of chronic conditions. Disease management programs, on the other hand, are designed to help employees who already have chronic disease, encouraging them to take better care of themselves through increased access to low-cost generic prescriptions or closing communication gaps in care through periodic visits to providers who leverage electronic medical records.

According to a 2012 Rand Corporation study, both program types collectively reduced the employer’s average health care costs by about $30 per member per month (PMPM) with disease management responsible for 87% of those savings. You read that right – 87%! Looking deeper into the study, employees participating in the disease management program generated savings of $136 PMPM, driven in large part by a nearly 30% reduction in hospital admissions. Additionally, only 13% of employees participated in the disease management program, compared with 87% for the lifestyle management program. In other words, higher participation in lifestyle management programs marginally contributes to overall short-term savings; ROI was $3.80 for disease management but only $0.50 for lifestyle management for every dollar invested.

This isn’t to say that lifestyle management isn’t a worthy cause – employers still benefit from its long-term savings, reduced absenteeism, and improved retention rates – but it cannot be ignored that short-term ROI is markedly achieved through a robust disease management program.

Strategy 2: Beef Up Value-Based Benefits

Value-Based Benefit Design (VBD) strategies focus on key facets of the health care continuum, including prevention and chronic disease management. Often paired with wellness programs, VBD strategies aim to maximize opportunities for employees make positive changes. The result? Improved employee health and curbed health care costs for both employee and employer. Types of value-based benefits outlined by the National Business Coalition on Health include:

Individual health competency where incentives are presented most often through cash equivalent or premium differential:
Health Risk Assessment
Biometric testing
Wellness programs
Condition management where incentives are presented most often through co-pay/coinsurance differential or cash equivalent:
Adherence to evidence-based guidelines
Adherence to chronic medications
Participation in a disease management program
Provider Guidance
Utilization of a retail clinic versus an emergency room
Care through a “center of excellence”
Tier one high quality physician
There is no silver bullet when it comes to VBD strategies. The first step is to assess your company’s health care utilization and compare it with other benchmarks in your industry or region. The ultimate goal is to provide benefits that meet employee needs and coincide with your company culture.

Strategy 3: Adopt Comprehensive Biometric Screenings

Think Health Risk Assessments (HRAs) and Biometric Screenings are one and the same? Think again. While HRAs include self-reported questions about medical history, health status, and lifestyle, biometric screenings measure objective risk factors, such as body weight, cholesterol, blood pressure, stress, and nutrition. This means that by adopting a comprehensive annual biometric screening, employees can review results with their physician, create an action plan, and see their personal progress year after year. For employers, being able to determine potentially catastrophic claims and quantitatively assess employee health on an aggregate level is gold. With such valuable metrics, its no surprise that nearly 51% of large companies offer biometric screenings to their employees.

Strategy 4: Open or Join an Employer-Sponsored Clinic

Despite a moderate health care cost trend of 4.1% after ACA changes in 2013, costs continue to rise above the rate of inflation, amplifying concerns about the long-term ability for employers to provide health care benefits. In spite of this climate, there are still high-performing companies managing costs by implementing the most effective tactics for improving health. One key tactic? Offer at least one onsite health service to your population.

I know what you’re thinking: employer-sponsored clinics are expensive and only make sense for large companies, right? Not anymore. There are a few innovative models out there tailored to small and mid-size businesses that are self-funded, including multi-employer, multi-site sponsored clinics. Typically a large company anchors the clinic and smaller employers can join or a group of small employers can launch their very own clinic. There are a number of advantages to employer-sponsored clinics and it is worthwhile to explore if this strategy is right for your company.

Strategy 5: Leverage Mobile Technology

With thousands health and wellness apps currently available through iOS and Android, consumers are presented with an array of digital tools to achieve personal goals. So how can self-insured companies possibly leverage this range of mobile technology? From health gamification and digital health coaching, to wearables and apps, employers are inundated with a wealth of digital means that delivering a variation of virtually the same thing: measurable data. A few start-ups, including JIFF and SocialWellth, have entered the field to help employers evaluate and streamline digital wellness offerings.
These companies curate available consumer health and wellness technology to empower employers by simplifying the process of selecting and managing various app and device partners, and even connecting with tools employees are already be using.

Conclusion:

Self-insured companies have a vested interest in improving employee health and understand that wellness is indeed a business strategy. High-performing companies are able to manage costs by implementing the most effective tactics for improving workforce health including an increased focus on Chronic Disease Management programs; strengthening value-based benefit design; adopting comprehensive biometric screening; exploring the option of opening or joining an employer-sponsored clinic; and leveraging mobile technology.

Which strategies or tactics are you considering to implement in 2015?

 

Source:

Spears, T. (2014 December 19). 5 Crucial Wellness Strategies for Self-Funded Companies[Web blog post]. Retrieved from https://www.careatc.com/ehs/5-wellness-strategies-for-self-funded-companies


SELF-INSURED GROUP HEALTH PLANS

Are you looking to switch your company's healthcare plan to a self-funded option? Take a look at this informative column by the Self-Insurance Institute of America and find out everything you need know when researching the best self-funded plan for your company.

Q. What is a self-insured health plan?

A. A self-insured group health plan (or a 'self-funded' plan as it is also called) is one in which the employer assumes the financial risk for providing health care benefits to its employees. In practical terms, self-insured employers pay for each out of pocket claim as they are incurred instead of paying a fixed premium to an insurance carrier, which is known as a fully-insured plan. Typically, a self-insured employer will set up a special trust fund to earmark money (corporate and employee contributions) to pay incurred claims.

Q. How many people receive coverage through self-insured health plans?

A. According to a 2000 report by the Employee Benefit Research Institute (EBRI), approximately 50 million workers and their dependents receive benefits through self-insured group health plans sponsored by their employers. This represents 33% of the 150 million total participants in private employment-based plans nationwide.

Q. Why do employers self fund their health plans?

A. There are several reasons why employers choose the self-insurance option. The following are the most common reasons:

  1. The employer can customize the plan to meet the specific health care needs of its workforce, as opposed to purchasing a 'one-size-fits-all' insurance policy.
  2. The employer maintains control over the health plan reserves, enabling maximization of interest income - income that would be otherwise generated by an insurance carrier through the investment of premium dollars.
  3. The employer does not have to pre-pay for coverage, thereby providing for improved cash flow.
  4. The employer is not subject to conflicting state health insurance regulations/benefit mandates, as self-insured health plans are regulated under federal law (ERISA).
  5. The employer is not subject to state health insurance premium taxes, which are generally 2-3 percent of the premium's dollar value.
  6. The employer is free to contract with the providers or provider network best suited to meet the health care needs of its employees.

Q. Is self-insurance the best option for every employer?

A. No. Since a self-insured employer assumes the risk for paying the health care claim costs for its employees, it must have the financial resources (cash flow) to meet this obligation, which can be unpredictable. Therefore, small employers and other employers with poor cash flow may find that self-insurance is not a viable option. It should be noted, however, that there are companies with as few as 25 employees that do maintain viable self-insured health plans.

Q. Can self-insured employers protect themselves against unpredicted or catastrophic claims?

A. Yes. While the largest employers have sufficient financial reserves to cover virtually any amount of health care costs, most self-insured employers purchase what is known as stop-loss insurance to reimburse them for claims above a specified dollar level. This is an insurance contract between the stop-loss carrier and the employer, and is not deemed to be a health insurance policy covering individual plan participants.

Q. Who administers claims for self-insured group health plans?

A. Self-insured employers can either administer the claims in-house, or subcontract this service to a third party administrator (TPA). TPAs can also help employers set up their self-insured group health plans and coordinate stop-loss insurance coverage, provider network contracts and utilization review services.

Q. What about payroll deductions?

A. Any payments made by employees for their coverage are still handled through the employer' s payroll department. However, instead of being sent to an insurance company for premiums, the contributions are held by the employer until such time as claims become due and payable; or, if being used as reserves, put in a tax-free trust that is controlled by the employer.

Q. With what laws must self-insured group health plans comply?

A. Self-insured group health plans come under all applicable federal laws, including the Employee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), the Americans with Disabilities Act (ADA), the Pregnancy Discrimination Act, the Age Discrimination in Employment Act, the Civil Rights Act, and various budget reconciliation acts such as Tax Equity and Fiscal Responsibility Act (TEFRA), Deficit Reduction Act (DEFRA), and Economic Recovery Tax Act (ERTA).

See the original article Here.

Source:

Self-Insurance Institute of America (Date). Self-insured group health plans [Web blog post]. Retrieved from address https://www.siia.org/i4a/pages/index.cfm?pageID=4546


Top 10 catastrophic claims for self-funded employers

Great read on what may impact your self-funded plan by Jack Craver. See results from the study below.

Original Post from BenefitsPro.com on July 13, 2016

There are a range of illnesses that can prompt a self-funded employer to make a claim on their stop-loss insurance policy, but a new study by Sun Life Financial Inc. finds that a majority (53 percent) of the $5.3 billion in such claims paid by insurers from 2012 to 2015 came from 10 ailments.

The study shows the incredible impact of cancer. All types of cancer account for more than a quarter of all stop-loss claims, with breast cancer alone accounting for 13 percent of the total reimbursements.

Claims that exceeded $1 million continue to be rare — only 319 during the four-year period — but they account for nearly a fifth of the total reimbursements.

This voluntary benefit is on the rise, driven by employers offering it to workers.

They have also steadily increased every year, from 60 in 2012 to 107 in 2015. The number of claims exceeding $2 million, however, has not risen steadily, jumping from two to 20 in 2013 but then dropping again in the subsequent two years.

"By highlighting the conditions that create catastrophic claims and providing insights into trends influencing high costs, we can help employers anticipate what they'll see when self-funding and raise awareness about the importance of cost-containment resources and stop-loss insurance,” says Brad Nieland, vice president of Sun Life Financial’s stop-loss division, in a press release.

Here are the top 10 ailments associated with self-funded employer claims:

10. Septicemia

A condition that arises when the body reacts violently to an infection, damaging critical organs in the process and in the most severe cases leading to septic shock, septicemia resulted in $54.7 million in reimbursements between 2012 and 2015, or 2.4 percent of the total.

9. Respiratory failure

Pulmonary collapse or respiratory failure was the ninth leading claim for self-funded employers, resulting in $55 million in reimbursements from stop-loss insurance policies. Risk factors for the condition include binge-drinking, smoking, and working in an environment that leads to inhalation of chemicals that irritate the lungs, all issues that employers can have a hand in improving.

8. Cerebrovascular disease

Most commonly manifested through a stroke, cerebrovascular disease or blood brain vessels prompted $57.4 million in reimbursements between 2012 and 2015, for 2.4 percent of the total. Although strokes are the fifth leading cause of death for Americans, but two-thirds of stroke patients are over the age of 65, suggesting the burden of caring for stroke patients falls mostly on Medicare, rather than employers.

7. Congestive heart failure

The condition that afflicts roughly 2 percent of the adult population and 5 percent of those age 60-69 resulted in $57.8 million in reimbursements from catastrophic insurance policies in 2012-15, accounting for 2.5 percent of the total.

6. Transplants

Transplants are becoming more common than ever, but the good news is that the operations are not as likely to force catastrophic coverage. While transplants increased 65 percent between 2012 and 2015, the total amount of stop-loss reimbursements paid because of transplants only ticked up 0.7 percent compared to 2011-14, to $62.2 million.

5. Premature births/low birth weight

Babies that are born prematurely and have to undergo long hospital stays in incubators or other treatment can prompt astronomical costs for patients and their employers. From 2012 to 2015, employers received $75 million in reimbursements related to such costs incurred by employees, or 3.2 percent of the total.

4. Congenital anomalies

The top claim that specifically relates to a condition at birth, congenital anomalies prompted $96.3 million in reimbursements from 2012 to 2015, holding relatively steady from the 2011 to 2014 period. That accounts for 4.1 percent of total reimbursements.

3. Chronic renal disease

Employers received $156 million from claims related to severe disease of the kidneys, accounting for 6.7 percent of the total. That is a 1 percent decrease from the 2011 to 2014 period. While the costs of treating the condition have decreased 21 percent in the past four years, the disease remains common and costly nonetheless. According to some estimates, chronic renal failure as much as 10 percent of the population, but it is the later stages of the condition that are the most severe and the most costly, often resulting in kidney transplants.

2. Leukemia/lymphoma/multiple myeloma

The second family of cancers is the No. 2 claim for catastrophic insurance. Its financial impact is great, but much smaller. Employers received $188 million between 2012 to 2015 from stop-loss reimbursements related to these conditions, accounting for 8.1 percent of total claims nationally. The value of such claims has remained steady in recent years.

1. Malignant neoplasm

The leading type of cancer is by far the leading reason that employers make claims on their stop-loss policies. These types of cancer accounted for 18.5 percent of all stop-loss claim reimbursements from 2012 to 2015, the study found, totaling a whopping $429 million. That represents a 0.9 percent increase over the 2011 to 2014 period.

See Original Article Here.

Source:

Craver, J. (2016, July 13). Top 10 catastrophic claims for self-funded employers [Web log post]. Retrieved from http://www.benefitspro.com/2016/07/13/top-10-catastrophic-claims-for-self-funded-employe?ref=hp-in-depth&page_all=1&slreturn=1468939510


5 Crucial Wellness Strategies for Self-Funded Companies

Original post careatc.com

Instead of paying pricey premiums to insurers, self-insured companies pay claims filed by employees and health care providers directly and assume most of the financial risk of providing health benefits to employees. To mitigate significant losses, self-funded companies often sign up for a special “stop loss” insurance, hedging against very large or unexpected claims. The result? A stronger position to stabilize health care costs in the long-term. No wonder self-funded plans are on the rise with nearly 81% of employees at large companies covered.

Despite the rise in self-insured companies, employers are uncertain as to whether they’ll even be able to afford coverage in the long-term given ACA regulations. Now more than ever, employers (self-insured or not) must understand that wellness is a business strategy. High-performing companies are able to manage costs by implementing the most effective tactics for improving workforce health.

Here are five wellness strategies for self-insured companies:

Strategy 1: Focus on Disease Management Programs

Corporate wellness offerings generally consist of two types of programs: lifestyle management and disease management. The first focuses on employees with health risks, like smoking or obesity, and supports them in reducing those risks to ultimately prevent the development of chronic conditions. Disease management programs, on the other hand, are designed to help employees who already have chronic disease, encouraging them to take better care of themselves through increased access to low-cost generic prescriptions or closing communication gaps in care through periodic visits to providers who leverage electronic medical records.

According to a 2012 Rand Corporation study, both program types collectively reduced the employer’s average health care costs by about $30 per member per month (PMPM) with disease management responsible for 87% of those savings. You read that right – 87%! Looking deeper into the study, employees participating in the disease management program generated savings of $136 PMPM, driven in large part by a nearly 30% reduction in hospital admissions. Additionally, only 13% of employees participated in the disease management program, compared with 87% for the lifestyle management program. In other words, higher participation in lifestyle management programs marginally contributes to overall short-term savings; ROI was $3.80 for disease management but only $0.50 for lifestyle management for every dollar invested.

This isn’t to say that lifestyle management isn’t a worthy cause – employers still benefit from its long-term savings, reduced absenteeism, and improved retention rates – but it cannot be ignored that short-term ROI is markedly achieved through a robust disease management program.

Strategy 2: Beef Up Value-Based Benefits

Value-Based Benefit Design (VBD) strategies focus on key facets of the health care continuum, including prevention and chronic disease management. Often paired with wellness programs, VBD strategies aim to maximize opportunities for employees make positive changes. The result? Improved employee health and curbed health care costs for both employee and employer. Types of value-based benefits outlined by theNational Business Coalition on Health include:

Individual health competency where incentives are presented most often through cash equivalent or premium differential:

  • Health Risk Assessment
  • Biometric testing
  • Wellness programs

Condition management where incentives are presented most often through co-pay/coinsurance differential or cash equivalent:

  • Adherence to evidence-based guidelines
  • Adherence to chronic medications
  • Participation in a disease management program

Provider Guidance

  • Utilization of a retail clinic versus an emergency room
  • Care through a “center of excellence”
  • Tier one high quality physician

There is no silver bullet when it comes to VBD strategies. The first step is to assess your company’s health care utilization and compare it with other benchmarks in your industry or region. The ultimate goal is to provide benefits that meet employee needs and coincide with your company culture.

Strategy 3: Adopt Comprehensive Biometric Screenings

Think Health Risk Assessments (HRAs) and Biometric Screenings are one and the same? Think again. While HRAs include self-reported questions about medical history, health status, and lifestyle, biometric screenings measure objective risk factors, such as body weight, cholesterol, blood pressure, stress, and nutrition. This means that by adopting a comprehensive annual biometric screening, employees can review results with their physician, create an action plan, and see their personal progress year after year. For employers, being able to determine potentially catastrophic claims and quantitatively assess employee health on an aggregate level is gold. With such valuable metrics, its no surprise that nearly 51% of large companies offer biometric screenings to their employees.

Strategy 4: Open or Join an Employer-Sponsored Clinic

Despite a moderate health care cost trend of 4.1% after ACA changes in 2013, costs continue to rise above the rate of inflation, amplifying concerns about the long-term ability for employers to provide health care benefits. In spite of this climate, there are still high-performing companies managing costs by implementing the most effective tactics for improving health. One key tactic? Offer at least one onsite health service to your population.

I know what you’re thinking: employer-sponsored clinics are expensive and only make sense for large companies, right? Not anymore. There are a few innovative models out there tailored to small and mid-size businesses that are self-funded, including multi-employer, multi-site sponsored clinics. Typically a large company anchors the clinic and smaller employers can join or a group of small employers can launch their very own clinic. There are a number of advantages to employer-sponsored clinics and it is worthwhile to explore if this strategy is right for your company.

Strategy 5: Leverage Mobile Technology

With thousands health and wellness apps currently available through iOS and Android, consumers are presented with an array of digital tools to achieve personal goals. So how can self-insured companies possibly leverage this range of mobile technology? From health gamification and digital health coaching, to wearables and apps, employers are inundated with a wealth of digital means that delivering a variation of virtually the same thing: measurable data.

These companies curate available consumer health and wellness technology to empower employers by simplifying the process of selecting and managing various app and device partners, and even connecting with tools employees are already be using.

Conclusion:

Self-insured companies have a vested interest in improving employee health and understand that wellness is indeed a business strategy. High-performing companies are able to manage costs by implementing the most effective tactics for improving workforce health including an increased focus on Chronic Disease Management programs; strengthening value-based benefit design; adopting comprehensive biometric screening; exploring the option of opening or joining an employer-sponsored clinic; and leveraging mobile technology.


Deadline Looms to Obtain Group Health Plan Identifiers

Originally posted October 17, 2014 by Stephen Miller on www.shrm.org.

updated 9/19/2014

Self-insured employers should take note of approaching deadlines under a Department of Health and Human Services (HHS) final rule that requires large health plans to obtain health plan identifiers (HPIDs) by Nov. 5, 2014; for small plans, the deadline is Nov. 5, 2015.

An HPID is intended to serves as a unique identifier for health plans involved in transactions subject to the Health Insurance Portability and Accountability Act (HIPAA). HIPAA defines a small health plan as one with annual receipts of $5 million or less.

Employers “are really struggling with the requirements for health plan identifiers,” said Gretchen Young, senior vice president for health policy at the ERISA Industry Committee (ERIC), in a news release. “Regulations issued by HHS were clearly not written with self-insured group health plans in mind.”

Clarification Sought

ERIC recently polled its members, who are large employers that sponsor benefit plans for their workers, and found that the vast majority of these companies had not tried to obtain an HPID as of September 2014. The poll indicated that nearly half of the respondents (45 percent) were still waiting, with hopes that HHS would publish relevant guidance.

For those members who have attempted to obtain an HPID, 100 percent found the process to be “very difficult” or “difficult,” Young said. Common problems included the lack of guidance from HHS regarding the manner in which self-insured plans should calculate the number of plans that need an HPID.

“Many plan sponsors use a single document that includes a variety of different benefit programs and they treat all of the benefit programs as a single plan for reporting purposes under ERISA. It is unclear whether companies would need to treat each type of benefit as a separate [controlling health plan] that needs its own HPID, even if they use a single document and their benefits are treated as a single plan for ERISA purposes,” explained Young.

“It is critical that HHS act quickly to address the deficiencies in the current guidance...given the lack of guidance and difficulties using their system,” she said.

Other Self-Funded Arrangements

“While it is the insurer that is responsible to obtain an HPID on behalf of fully insured health plans, plan sponsors of fully insured health plans should be aware that an HPID may be required for other self-funded arrangements,” cautioned Tripp Vander Wal, an attorney with law firm Miller Johnson, in an online article.

Examples of these self-funded arrangements include health reimbursement arrangements (HRAs) or medical flexible spending accounts (FSAs). “The good news is that HRAs and FSAs are likely to qualify as small health plans and have an additional year to obtain an HPID,” he noted.

Update: 

In a subsequently issued set of FAQs, the Centers for Medicaid and Medicare Eligibility stated that neither health FSAs nor HSAs are required to obtain an HPID because they are “individual accounts directed by the consumer to pay health care costs.” In addition, CMS stated that whether an HRA needs an HPID depends on what it reimburses. HRAs that cover only deductibles or out-of-pocket costs do not require HPIDs; however, HRAs that pay for other costs (e.g., health insurance premiums) still need HPIDs.

Commented law firm Alston & Bird LLP in an Advisory Update, “We note that, while this guidance may appear to be welcome news for employers with only fully insured plans and health FSAs or HRAs (whose only potential HPID enumeration responsibility would be because of the health FSA or HRA), it is not consistent with HIPAA’s definition of health plan, under which both health FSAs and HRAs are health plans, as CMS has previously recognized. Employers should be able to rely on CMS’s clear statement in this guidance that FSAs and certain HRAs do not require HPIDs, but we advise caution. Given the inconsistency with previous guidance on FSAs and HRAs and the manner in which CMS has phrased the FAQ, the guidance may not create as broad an exception as it first appears.”


Groups defend small self-insured plans

Originally posted November 14, 2013 by Allison Bell on www.benefitspro.com

Defenders of self-insured health plans testified on Capitol Hill today that the plans are tools for employers to get more control over benefits programs, not get-out-of-federal-health-regulation free cards.

The witnesses — including Robin Frick, a Madisonville, La., benefit plan administrator, who spoke on behalf of the National Association of Health Underwriters, and Michael Ferguson, the president of the Self-Insurance Institute of America, appeared at a hearing on self-insurance organized by the House Small Business Committee health subcommittee.

Some health policy watchers, including Linda Blumberg of the Urban Institute, who also testified at the hearing, have suggested that young, healthy small groups could use self-insurance simply to escape from Patient Protection and Affordable Care Act requirements, and that a flight toward self-insurance could destabilize the small-group health insurance market.

Frick told subcommittee members that most PPACA market protection rules will apply to self-insured groups as well as to insured groups.

"Further, some protections, like non-discrimination testing, already apply to all self-funded plans," Frick said, according to a written version of his remarks posted on the committee website.

The U.S. Department of Health and Human Services is giving more flexibility to insured plans in some areas, such as employee participation requirements, than to self-insured plans, Frick said.

Ferguson gave a list of some of the many PPACA rules that apply to non-grandfathered self-insured plans, including the ban on annual and lifetime benefits limits, preventive services coverage requirements, benefits summary requirements, disclosure requirements, external claim denial review requirements, limits on waiting periods, and an emergency services coverage mandate.

Many of the PPACA provisions that exempt self-insured groups, such as PPACA health insurance rate rules, are irrelevant to self-insured groups, because the self-insured plan sponsors already have an obvious incentive to try to hold down administrative costs, Ferguson said.


Self-insured win partial PPACA fee exemption

Originally posted October 28, 2013 by Dan Cook on www.lifehealthpro.com

Self-insured employers and self-administered health plans are about to catch a break, thanks to fine-tuning of the Patient Protection and Affordable Care Act by the Department of Health and Human Services.

In a soon-to-be-published compendium of rule modifications, HHS says it will exempt certain self-insured employers from the second two years of paying the reinsurance fee.

HHS says the proposed modifications — of which there are quite a few — are the result of its “listening” sessions with interested parties about specific requirements of the act. The full list can be found in the proposal, “Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to the HHS Notice of Benefit and Payment Parameters for 2014.”

HHS doesn’t offer a whole of detail on the exemption matter. It says in order to address employer feedback that the fees are burdensome, it will accept payment of the fee in two chunks instead of one (at the beginning of 2014 and at the end of the year) and will “exempt certain self-insured, self-administered plans from the requirement to make reinsurance contributions for the 2015 and 2016 benefit years” in future rulemaking and/or guidance proposals.

However, all employers will be required to pay the first-year fee for the program, which begins in 2014.

The 2014 fee for the three-year Transitional Reinsurance Program was set at $63 per plan participant. Fee levels have not been set for 2015 and 2016.

The fees are designed to yield $25 billion over the three-year program – money that would help offset costs incurred by insurers covering high-cost individuals purchasing coverage in public insurance exchanges.

HHS’s missive addressed other matters, including what happens when a small company buys small group insurance, and then it becomes a large company. The employer can keep the small group insurance package as long as it doesn’t make substantial modifications to it. But if discontinues small group coverage, it will then have to purchase insurance through the large group exchanges.

HHS also promised to provide further guidance on the sticky issue of what constitutes a fulltime employee for purposes of the all-important employee head count.

The proposals are scheduled to be published in the Federal Register on Wednesday.


Cost savings attributed to self-funding, wellness

Originally published September 6, 2013 by Tristan Lejeune on http://ebn.benefitnews.com

Dianne Howard has understandably made a number of changes during her tenure as director of risk and benefits management with the School District of Palm Beach County, Fla. - after all, she's been there for 18 years. One change in particular six years ago paved the way for many other beneficial ones: The district went self-funded. It's a shift that may not be an option for many employers, but Howard - winner of the 2013 Benny Award for Benefits Leadership in Health Care - says it allowed her to be more hands-on with internal policies and institute real, lasting improvements.

"I'm a big believer in self-insurance," Howard says. "I think you can buy excess insurance to protect yourself, you know, specific and aggregate. You can't be too small, but for groups of 1,000 or more, it's the way to go. You can control things, you can subcontract, you can get in there and say, 'Well, why is this costing us so much money?'"

She recalls an incident where MRIs - hundreds of them in total - were being paid for without having the deductible applied. Providers never informed them of this until the district took the reins themselves; they had just assumed that hospital stays were involved.

"And it was just a mistake - I'm not trying to throw anybody under the bus - but because we looked at it, we could fix it and change it so that the design as we negotiated [it] was in there, and we're getting the savings that we thought we would get," she says.

After going self-insured, the district used a data warehouse to analyze its claims and find ways to control costs. Estimated savings? At least $4 million. It also added a tobacco surcharge to insurance plans and helped write the Florida law banning smoking on school property. But the initiative Howard is most eager to talk about is one that has been widely embraced even as its financial efficacy has been increasingly questioned: wellness.

Not an easy sell

Many who have tried it will tell you that initiating a wellness program is not the easiest sell to an employee population. Just ask Howard: "People don't like being told what to do," she says, and she saw quite a bit of resistance. That's normal enough for a private company, but Howard's position comes with extra challenges.

"We're a public entity, so noise gathers," she says. "It doesn't just come to me and my staff. It goes to me, to my boss and maybe to our school board. You just want to be able to defend your position, get it well-communicated and get the unions on board to help you communicate. We told them, 'If it works and we keep our rates down, maybe we won't need rate increases every year.' And for 2014, we're not going to need a rate increase."

Marilyn Boursiquot, benefits manager for the district, agrees that wellness was not exactly a welcome change for employees, but she says the work is paying off.

"Our culture is slow, and some folks are still being dragged along kicking and screaming, but we can truly say that we're starting to see the light of creating a culture of wellness, which is really exciting," Boursiqout says.

Howard's "tenacity" and her "willingness to be on the edge" has helped steward the district through year after year of change, Boursiquot says. And she thinks that's what makes Howard worthy of her Benny Award.

"When we look at other school districts, and just other employers in general, they're willing to go to a point, but then when the rubber hits the road ... it's not always easy to introduce programs like this," Boursiquot says. "You take flak for it. And to actually keep moving forward in spite of all that - that's what I really admire about her."

Medical trends

The School District of Palm Beach County boasts an average five-year medical trend of 6% - 4% below the industry median of 10%. It also shed 1,000 dependents (estimated long-term savings: $4.4 million) after an audit found them ineligible - one of many reviews made possible through self-insurance.

Howard, however, believes the wellness program has been helping keep costs down for the district, which has 20,000 full-time employees. It was a slow road, she says, and the program "evolved" from weak to strong.

"We started out by saying, 'Here's a health assessment you could do.' In a district our size, we got 25 people to do it, and we gave gift cards at the time," she says. "And that really was poor. So about four or five years ago, we started talking with the unions, and we found a different way to negotiate with them and said, 'Let's bargain something two years out,' and that gave them time to think and to plan.

"We wanted to get to the point where employees have to get blood work, so they know their condition, and get a physical. ... More than half our employees never saw a doctor. So we said, 'OK, preventive stuff is what we should do,' so we had talks with our carrier about what's important, and we figured the health assessment was very important."

The district upped the reward for HRA completion substantially to a $50 premium reduction per month. "And that number," Howard says, "really was motivating to our employees." In its first year, the new program saw 85% compliance. And now, as she says, health insurance costs won't rise for workers next year. This, too, is a bigger deal for a public entity.

"We're government employees," Howard points out. "We haven't had raises in a few years."

Of course, even wellness programs' biggest proponents will admit they can only get you so far; the district has had to do its share of belt-tightening. Copays and premiums have risen in recent years, and there are newly designed pharmacy tiers, too.

Estimating in 2010 that diabetes accounted for 20% of its health claims, the district implemented a diabetes health plan. In its first year, the plan reduced total net costs by 9%, or around $2.9 million.

In another "self-funded only" gain, the district now gets 100% of its pharmacy rebates, which not only helps its coffers but also future plan design.

"Our rebates are approaching $5 million a year, and that's money that goes right back into the health plan," Howard says. "We had no idea it was so much money - only self-insured employers do."

Schools run mini-programs

But Howard again credits the district's wellness plans for starting long-term change. Schools, she says, can be excellent incubators for mini-programs that could work just as well at businesses with multiple locations. In addition to administrative offices, the Palm Beach County district runs some 180 locations, serving approximately 176,000 students.

"We had what we called 'wellness champions' at each school," Howard says. "What we said we would do is give them some resources so that they could run a program for their school - if they wanted to run a class on exercise or Weight Watchers or whatever. We have two big meetings a year with them, we give them a $500 stipend out of our health budget and for that they have to do a certain number of programs at their school. ... We went from 30 to 170 [wellness champions] in four years. And each of those people can [reach out] to the 200 to 400 people at their school and they know them."

Employees might be more amenable to such programs when they're initiated by a friendly co-worker and not some distant HR office. Making it personal and fun helps, too: In a different effort, called the Apple-a-Day Program, participants can submit photos of themselves eating apples while walking, reading medical care info or doing other healthy things. Howard says vendors donated prizes for the best photos, and local orchards even donated some apples. It's definitely a program she plans to repeat.

Kimberly Sandmaier, Palm Beach County wellness coordinator, admires Howard for her dedication and knows the district health plan is in good hands. "She's worked so hard with all our programs," Sandmaier says, and positive results are coming in on all fronts.

"I've always looked up to her and seen her as a leader. Whether it's meeting with a vendor or the unions, she gets a lot of respect from them. I think she does a great job, and she handles everything with grace."

As for what lies ahead, Sandmaier says, "We're trying to be proactive. We're trying to figure out the best thing out there to reduce our health care costs, especially in light of everything that's happening with health care reform and some of the additional charges that we may see in the future."

In the next phase of evolution, Howard plans to make her wellness programs results-based. Though she concedes it "may be not quite as successful," she remains optimistic.

"I think people are going to do it. I mean, you're taking the blood work anyways," she says. "Ideally people will say 'I've been doing the blood work for three years, I've had high blood pressure for three years - why don't I do something about it?' But that might not happen."

Whether self-insured or not, whether public or private, Howard recommends employers commit to wellness. "I really believe that you need a wellness component and work toward having your population having a little accountability in your health care," Howard says. "Don't give up when the noise gets a little loud. Use your data to show people, 'Look, this is what happening.' I just really believe in it; it's been good for us."

The numbers

Here are just a few of the results achieved by the School District of Palm Beach County under Dianne Howard's leadership:

2007: Switch to self-funded plan.

0: Cost increase in 2014 for self-funded medical plan.

6%: Average five-year medical trend.

100: Percentage of pharmacy rebates now received.

$4 million: Savings achieved from using a data warehouse to dig into claims to see where the school district was spending the most money and analyze what could be done to control those costs.

1,000: Number of dependents moved off the health plan thanks to a dependent eligibility audit.

$4.4 million: Estimated savings from dependent eligibility audit.

80%: Average participation rate in the wellness program.

$2.9 million: Estimated savings from the implementation of a diabetes health management program.

$600: Annual tobacco surcharge.

195: Number of wellness champions, up from 16 a few years ago.