mec with limited benefits 06182015
TRANSCRIPT
Minimum Essential Coverage Plans (MEC) with Limited Benefits
With
Healthcare Concierge Services
MEC Plan DetailsMinimum Essential Coverage Plan –
What is Minimum Essential Coverage?Minimum Essential Coverage is the type of coverage employees need to avoid the fee for not having insurance under the Affordable Care Act. In order to be in compliance with the law, employees must maintain minimum essential coverage or pay a fee for each month without it..
What Doesn’t Count As Minimum Essential Coverage?Minimum essential coverage does not include coverage providing only limited benefits, such as coverage only for vision care or dental care. Supplemental insurance will not help employees avoid the fee on their own. Concierge Benefit Service MEC/ Limited benefits plan will help employees avoid the fee.
What is Employer Responsibility?In 2016, Employers with 50+ FTEs will be subject to a penalty for: (1) failing to offer health care coverage to full time employees; ( 2) offering minimum essential coverage that is unaffordable; or (3) offering minimum essential coverage where the Plan pays less than 60% of cost. Do MEC Plans provide solutions?The January 1, 2015 mandate states employers with 100+ employees must have implemented the Minimum Essential Coverage. Beginning January 1, 2016 employers with 50+ employees must implement Minimum Essential Coverage to satisfy one portion of the ACA’s large employer mandate. While MEC plans eliminate the $2,000 per employee penalty, employers should be aware that these plans do not protect them from the ACA’s $3,000 penalty per each employee who goes to a public exchange and qualifies for a federal subsidy.
MEC Plan DetailsMinimum Essential Coverage Plan –
What Doesn’t Count As Minimum Essential Coverage?
Minimum essential coverage does not include coverage providing only limited benefits, such as coverage only for vision care or dental care, and Medicaid covering only certain benefits such as family planning, workers’ compensation, or disability policies.
Most insurance types offered between each years open enrollment will be short term health insurance, fixed benefit plans and supplemental insurance will not help you avoid the fee on their own, although they will help you be covered health-wise.
The following types of health insurance are not minimum essential coverage:Short Term Health PlansFixed Benefit Health PlansSupplemental Medicare like Part D and MedigapSome Medicaid covering only certain benefitsVision only, Dental only, and limited benefit plansGrandfathered Plans (You will avoid the fee, but won’t get the new rights and protections)
MEC vs MVP For health insurance to be considered minimum essential coverage it must typically have the following qualities:
• Affordability: Plans must cover, on average, at least 60% of out-of-pocket costs on required services. They also have limits on annual deductibles and out-of-pocket maximums. Applies to both MEC and MVP.
• Guaranteed Availability of Coverage: You cannot be denied coverage for any reason other than the ability to pay. Both MEC and MVP.
• Guaranteed Renewability of Coverage: You must be able to renew the policy regardless of health status. Both MEC and MVP.
• Fair Health Insurance Premiums: There are limits to the amount you can be charged based on age, tobacco use, family size, and geography. Both MEC and MVP.
• Medical Loss Ratio (the 80/20 Rule): If an insurance company spends less than 80% (85% in the large group market) of premium on medical care and efforts to improve the quality of care, they must rebate the portion of premium that exceeded this limit. Applies to MVP, wont come into play with MEC, well more than 80% of premium paid for Preventive Care Services and Limited Benefits are used to improve the care. Basically, cannot have large administration cost in premiums.
• Essential Benefits: Must provide coverage of at least ten essential health benefits. Both MEC and MVP or any plan.
• Dollar Limits: Insurers cannot place annual or lifetime dollar limits on Essential Benefits. Preventive Care Services cannot be capped by dollars.
Difference between MEC and MVPTo meet the Minimum Value Plan requirement, a plan must cover, on average, at least 60 percent of total allowed costs – i.e., what the plan pays versus what the customers pays due to deductibles, copays and coinsurance. Plans must also have a reasonable out-of-pocket maximum. This essentially means employer sponsored plans must offer at least the affordability and benefits of a Bronze plan sold on the marketplace.
MEC Plans Provide Real Solutions
Keep in mind for the January 1, 2015 mandate, employers with 100 or more employees must have implemented the Minimum Essential Coverage, at least. However, beginning January 1, 2016 employers with more than 50 employees must implement Minimum Essential Coverage to satisfy one portion of the ACA’s large employer mandate.
This allows the employer to avoid paying the $2,000 assessment per full-time employee for not meeting the Minimum Essential Coverage employer requirement. In addition to avoiding the tax, the employer contribution is a taxable expense.
While MEC plans eliminate the $2,000 per employee penalty, employers should be aware that these plans do not protect them from the ACA’s $3,000 penalty per each employee who goes to a public exchange and qualifies for a federal subsidy.
MEC plans can save employer’s costs related to benefits. Because MEC plans offer minimal coverage, the cost is less than traditional group health insurance. The premiums can be paid by the employer, the employee or co-funded.
MEC Limitations
When you examine these plans, it is important to understand the limitations of MEC plans.
MEC plans are not major medical coverage, they do not satisfy all ACA requirements and as such, they are not a solution for every employer.If you have someone tell you that they have a MEC silver bullet, our advice is to be extremely cautious and be sure to get a second opinion.
That said, there are MEC plans with really innovative plan designs that really can be a viable solution for certain industries that have low-wage, high turnover staffs…an example of which would include: convenience stores, retail, restaurants, staffing companies, nursing homes, home health care, hotels and resorts/casinos and security companies.
MEC Innovation
What to look for in a good MEC plan. Having an innovative plan design will bring better benefits to your employees and can be done for surprisingly low costs. The components of a good MEC plan design combines the benefits of the standard minimum essential coverage that are required to be offered by all MEC plans, with a limited or unlimited number of doctor and emergency room copays, prescription copays, unlimited use of telemedicine, medical bill negotiation services, non-emergency surgery saver benefits and patient advocacy. The standard minimal essential coverage for MEC plans pay for preventative care services only but when wrapped with these other benefits, these plan designs are more appealing to the workforce and much more affordable than standard indemnity health plans.
The MEC Administration
What truly separates one MEC plan from another is the organization that administers and services your plan.
Having access to multiple plan options with multiple insurance carriers is always the best showing of what an organization actually brings to the table.
We all know that one insurance carrier cannot be all things to all people. So shopping the marketplace is crucial for getting the best plan for your specific situation.
We strongly suggest against working with the organizations where you experience the inevitable “hand off” that occurs when the salesperson passes the account to a service provider.
This type of hand-off many times means that the salesperson is never held accountable for the promises they made and also means that the salesperson is rarely there to hold the insurance carrier accountable as well.
MEC Plan DetailsMinimum Essential Coverage Plan – Physician Office Visit, Prescription Drug Coverage & Preventive Care Services
What is a controlled group?Large employers may think that subdividing into smaller companies may provide relief from the Employer Mandate, PPACA and its regulations. The IRS defines “controlled group”. The controlled group rules essentially state that all employees which are under common control are to be treated as employed by a single employer.
3 types of “controlled groups1. parent-subsidiary groups, one business owns 80% or more of another business or businesses
2. brother-sister groups, five or less common owners; common owners must own at least 80 percent of each business; and the combined identical ownership must be 50 percent or more
3. combined ownership groups, each organization is a member of either a parent-subsidiary or brother-sister group and at least one corporation is: the common parent of a parent-subsidiary and a member of a brother-sister group
MEC Plan DetailsMinimum Essential Coverage Plan – Physician Office Visit, Prescription Drug Coverage & Preventive Care Services
Minimum Essential Coverage meets 2015 ACA Requirements Routine Physician Office Visits Accident Benefit Employee Assistance Program COBRA Administration HIPAA Administration Aggregate Stop Loss PPACA Summary of Benefits Coverage National PPO Network Administrative and Financial Data Compliance Employee relieve from ACA Penalty
Prescription Drug Plan Retail and Mail Order Generic Only
Telemedicine Call/Email/Videochat a Physician 24/7/365 English and Spanish speaking
Medical Bill Negotiation and Surgery Saver Negotiates medical bills on your behalf Compare pricing, quality, and availability of Surgery facilities
Discount Cards Discounts on Vision, Dental, Labs, MRIs and Prescriptions
Preventive Care ServicesPreventive Care Services
Benefits are payable for eligibility procedures incurred as part of Preventive Care Services only.
Covered Preventive Expense Benefit Level Limits
Included Preventive Care Services specified by Health Reform Law, USPSTF.
100% Some services are subject to age and visit limitations unless medically necessary
Preventive Care Services include but are not limited to:
1. Routine Physical Exam2. Annual Well Woman Exam3. Annual Routine Mammogram (age 40+)4. Routine Bone Density Test (age 60+)5. Well Baby Exam and Well Child Exam6. Routine Immunizations7. Routine Hearing Screening (newborn)8. Influenza/Pneumococcal Vaccine9. All FDA approved women’s contraception methods10. Routine Colonoscopy (age 50+)11. Routine vision screening (age 19+)
For a complete list:http://www.uspreventiveservicestaskforce.org
Covered Preventive Services Includes:• Adults• Children• Women, including Pregnant Women
List of ACA Preventive Care Services
MEC Employer and Employee Responsibility• Minimum Essential Coverage (MEC) need only to cover 100% of the CMS listed Preventive and Wellness benefits
• Employer with 50 employees or more full time plus part time equivalents can prevent being taxed $2000 per FTE, less 30 employees
• Employees can prevent being taxed on the Individual Mandate coverage penalty. 2015 – greater of 2% of household income or $325 per adult plus $162.50 per child
• Employers can charge any reasonable amount which typically is 50% of contributions, and cannot charge more than 9.5% of the household income
• Under a Limited Medical Plan the maximum out of pocket the Federal regulators allow is $6350 for a single employee.
www.conciergebenefitservices.com
Limited Benefits
The insurance described in this proposal provides limited benefits. Limited benefits plans are insurance products with reduced benefits and are not intended to be an alternative to or integrated with comprehensive coverage. This insurance does not coordinate with any other insurance plan. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.
Our voluntary benefit solutions provide:
• Benefits tailored to the specific needs of your employees.
• Turn-key implementation and setup.
• Ongoing premium reconciliation, carrier reporting and payroll deduction feeds.
We allow you to focus on your core medical plan offerings by providing a complete solution for your voluntary benefits.
www.conciergebenefitservices.com
Limited BenefitsHighlights of Technology Capabilities
• Online and paper enrollment
• Enroll, quote, bind and issue
• Custom employee web portal for enrollment and self-service
• Integrate non-Ternian products into enrollment and billing administration
• Real-time eligibility
• Resource library for insurance certificates, ID cards, plan information, forms
• Member service online chat and email
• Ad-hoc enrollment and eligibility reporting
• Enrollment and premium administration of employer’s self-funded limited benefit medical plan
The insurance described in this proposal provides limited benefits and Minimal Essential Coverage. Limited benefits plans are insurance products with reduced benefits and are not intended to be an alternative to comprehensive coverage. This insurance does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance.
www.conciergebenefitservices.com
Limited Benefit Plan Details
OUTPATIENT• Physician Office Visit Co-pay $10• Benefit Amount per Day $50 per day x 5 days• Accident Max Benefit amount per Year up to: $1,000 per year• Benefits % Payable 80% U&C
PRESCRIPTION• Retail- Generic Rx Copay $10• Mail Order – Generic Rx Copay $30•• Monthly Benefit Max Individual/Family $200/$400
AD&D• Accidental Death & Dismemberment Benefit $5,000
OTHER SERVICES• Telemedicine• Medical Bill Negotiation• Surgery Cost Saver• Employee Assistance Program• PPO Discounts• Discount Card for Dental, Vision, Lab Services
ACA Compliance and Administration Services
• Communication materials/Implementation Guidelines
• Plan Design and Summary of Benefits and Coverage
• Monthly reporting
• COBRA reporting
• TPA portal access
• HIPAA compliance
• Billing options
• ID Cards
• Claims processing
• 800 number for customer service
• Plan Implementation and Set up
• ACA compliance
Implementation Initial Start-Up
RFC Form Completed and Submitted Applicable Implementation Forms Completed and Submitted
Initial call to review RFC form
Review and Choice of materials options
Client's Logo sent
Determine Open Enrollment (OE) start/end dates
Determine schedule for (wkly) implementation callsConfirm Team Members to Create Implementation Contact List
IT/Enrollment/Reporting Set-Up
Website Setup/User Testing by Client Reporting Guide Discussion/Q&A
Determine Communication Strategy/Rollover Process
Sample file formats for enrollee/premium report sent to employer
File Testing
Sample import file sent from Ternian to Client
Rollover Data Spec Template to Employer
Production Eligibility Rollover File Received
Open Enrollment (OE) Begins
Open Enrollment (OE) Ends
Initial Effective Date for OE enrolled
Production Eligibility File Received and uploaded to CMS
Materials / Communications Prep & Distribution
Preparation of Materials proofs
Review/Approval of Materials proofs
Drafting & approval of Rollover letter to Current Enrollees
Current enrollee rollover & address info
Location Address list from Client
Material Order placedCOBRA participant data sent by Employer to Ternian
Materials - target ship date
Materials expected receipt date
Rollover Letter mailing release date Initial Member Materials processed/mailed
COBRA materials sent to current participants
ID Cards sent to membersOngoing Update Eligibility Files to Ternian/Discussion
Update Enrollment Files to Employer/ Discussion
New Hires/Terms/Missed PremiumProducer Kit
Administrative guide
Sample ID Card
Telemedicine
Sample Invoice
Sample Inc. 7310 N 16th St Ste 228Phoenix, AZ 85020
602-216-0006 Main
602-216-0026 Faxwww.Ternian.com
Sample, Inc. Prepared Date: 10/05/2014
9299 W. Olive Ave Suite 311 Invoice Number: SA0003
Dixon, CO 80045 Account Number: 8475999
Coverage Period: 10/01 TO 10/31/2014
Attn: Payment Due: 10/31/2014
HR Director
SUMMARY OF ACCOUNT
Opening Balance $1,217.04
Current Inforce Charges $776.04
MEC Administrative Fee $297.00
Composite Aggregate Premium Rate $162.00
Terminations/Credits $0.00
Retroactivity/Other Adjustments $0.00
Net Charges $1,235.04
Total Payments Received Since Last Invoice $1,217.04
AMOUNT DUE $2,452.08
Please Note: The total premium and administrative fees are due by the Payment Due date listed above. You may notify
us of any adds/terms/changes to employee coverage by making comments on the attached Enrollee Detail Report
and submitting it with your premium payment. However, we ask that you please pay the total Amount Due.
Premium and administrative fee adjustments for adds/terms/changes will be reflected on your next monthly invoice.
Questions? Contact 602 216-0006
Please include your invoice number and account number on your check.
Please detach & return with payment
logo here
Prepared Date: 10/05/2014
Invoice Number: OSB0003
Make checks payable to: Account Number: 8475384
abc Coverage Period: 10/01 TO 10/31/2014
Payment Due: 10/31/2014
Remittance Address:
abc
7310 N 16th St #228 Please Pay By: Amount Due
Phoenix AZ 85020 10/31/2014 $2,452.08
One Step Beyond, Inc.
Invoice will also include detailed breakdown by division
Telemedicine ServicesAt Concierge Benefit Services, our focus is making your life less complicated. Utilizing technology along with cutting edge services in the Telemedicine arena has set us apart.
We provide you and your family with access to the most innovative and cost effective approach to a doctor’s office visit and physician care available.
As one of the nation’s premier leaders in the telemedicine industry, Concierge Benefit Services offers consumers access to some of the most cutting edge, innovative healthcare solutions in the nation. Our focus is to help consumers save money on their healthcare costs. By providing phone, email and/or video conferencing access to a national network of U.S., board certified, licensed physicians, our program gives consumers near immediate access to care…anytime they need it, from anywhere.
All physicians are independent providers and are credentialed. The credentialing process is performed by a national third party credentialing agency in accordance with the National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Committee (URAC) guidelines. Credentialing includes a thorough review of medical licensure, training, education, work and malpractice history.
Our telemedicine portfolio provides fast and convenient access to quality medical care 24 hours a day, 7 days a week, 365 day a year throughout the United States. This approach is a very inexpensive alternative to non-emergency related Emergency Room visits, Urgent Care Clinic visits or even Primary Care Physician visits.
Telemedicine Service- Finally… a doctor’s offi ce that you can access immediately from the comfort of your own home, offi ce, car, etc!
• No more waiting rooms
• No more copays
• 24/7/365 access to a board-certified doctor…anywhere, anytime
• As simple as 1…2…3!• Call a doctor• Get diagnosed• Pick up prescriptions
Telemedicine Services
Telemedicine Services
Telemedicine Reduces Cost
Telemedicine’s Common Conditions and Common Prescriptions
Concierge Benefits are for the Entire Household
Great Benefit for the employee and families of:FT employeesPT EmployeesSeasonal Employees
Results include:Employee RetentionMorale BuilderLess time away from workDiscounts on Vision and DentalDiscounts on Labs and MRI services
Healthcare Concierge Telemedicine Return on Investment/Potential Savings
AVG Cost perIncident w/o CopayHealthcare Concierge Cost
$240.00
$6.00
Per IncidentSAVINGS
$234.00
Example: Family of 4 with 3 Doctors Visits per family memeber per YearAnnual Family Saving per Year
Savings
Total Annual Cost of Healthcare Concierge for Family
Out of Pocket Cost for entire Famly
$2,880
$179
% of ER visits and Office visits that can be
handled over the phone
Over
70%
% of Doctor consults that result in not having to
leave work
Over
50%
Simple Process
1. Call the Doctor2. Get diagnosed3. Pick up your prescription
SAVINGS
Medical Bill Negotiation
Professional negotiators will negotiate medical bills on your behalf directly with the healthcare provider to reduce or eliminate the balance due.
Aggregate medical bills of $1,000 (per Incident) or more will be negotiated to save the member first dollar costs.
• Our average savings have been:• Over $1,800 per case for those with health insurance and Over $4,000 per case for
individuals with no health insurance coverage
Patient Advocacy and Medical Bill Negotiation Services – Unlimited Use
Surgery Cost Saver
An RN will Surgery Cost Saver and Facility Comparison – How important would it be to have complete transparency in your surgical procedures and cost prior to choosing where you will have a non-emergency surgical procedure?
l develop a healthcare facility comparison report for non-emergency surgical procedures. The report will compare pricing, availability, and quality metrics for up to five area facilities.
Average savings:64% price differential among compared facilities Average savings over $13,000 per caseUnlimited use
Complete Transparency in your Surgical Procedures and Cost prior to the Surgery
Medical Bill Negotiation and Surgery Cost Saver
Cost Containment Services
Patient Advocacy and Medical Bill Negotiation Services – How great would it be to have access to professional medical bill negotiators who negotiate medical bills on your behalf?
Professional negotiators will negotiate medical bills on your behalf directly with healthcare providers to reduce or eliminate the balance due. Aggregate medical bills of $1,000 (per Incident) or more will be negotiated to save the member first dollars.
Our average savings have been:• Over $1,800 per case for those
with health insurance• Over $4,000 per case for
individuals with no health insurance coverage
• Unlimited use.
Surgery Cost Saver and Facility Comparison – How important would it be to have complete transparency in your surgical procedures and cost prior to choosing where you will have a non-emergency surgical procedure?
An RN will develop a healthcare facility comparison report for non-emergency surgical procedures. The report will compare pricing, availability, and quality metrics for area facilities.
Average savings:• 64% price
differential among compared facilities
• Average savings over $13,000 per case
• Unlimited use
Discount Services
Discount Health Benefits
• Dental Benefits15-50% Savings!
• Vision and Hearing Plans10-60% Savings!
• Labs and Imaging15-80% Savings!
• Chiropractic and Alternative Medicine20-40% Savings!
Discount Card Sample
Employee Assistance Program
Welcome to SupportLinc, a CuraLinc Healthcare service. With SupportLinc as your Employee Assistance Program, you have immediate access to expert content and comprehensive tools to assist you in every aspect of your life, all in a secure, confidential and easy-to-use format.
At some point in our lives, each of us faces a problem or situation that is difficult to resolve. When these instances arise, SupportLinc will be there to help.
The SupportLinc Employee Assistance Program (EAP) is a confidential resource that helps you deal with life’s challenges and the demands that come with balancing home and work.
SupportLinc provides professional counseling and referrals for a wide array of personal and work-related concerns.
First Health PPO Medical NetworkAccess to Network discounts to more than 5,000 hospitals and
590,000 physicians and health care professionals. Service
provides members affordable access to physicians by allowing
them to pay a $10 Office Visit Pre-pay before insurance benefits
are applied.
Pharmacy NetworkWith RxEDO, members can use their card for prescription fills and refills at over 56,000 participating pharmacies for co-pay benefits that will be processed in real-time at the point-of-purchase at the pharmacy.
SupportLinc Employee AssistanceThe SupportLinc Employee Assistance Program (EAP) helps you deal with life’s challenges and the demands that come with balancing home and work. SupportLinc provides confidential, professional referrals and up to three (3) face-to-face counseling sessions for a wide array of personal and work-related concerns.
ternian Administration of MEC – Preventive Care and Limited Med Benefits
PARTNERS
Contact Concierge Benefit Services
Sheldon Lee – VP, Bus. [email protected] [toll free]
www.conciergebenefitservices.com
No Contracts No Hidden Fees Complete Transparency
Got Questions? Need a Proposal or Comparison of Your Current Plan?