insurance guidestone for administrators
DESCRIPTION
guideTRANSCRIPT
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Donna Lively Director, Insurance Marketing GuideStone Financial Resources
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Today’s Agenda:
1. The basics of medical insurance
Basic terminology
Concepts
2. Selecting the right plan for your employees
Comparing plans
Premiums & coverage
Employee costs
Employee needs
5 pitfalls to avoid
3. Questions?
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THE BASICS OF
MEDICAL INSURANCE
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The Rising Cost of
Healthcare
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Did You Know?
•2009 was the 10th consecutive year of double-
digit healthcare cost increases
•2010 first year in a decade without a double-digit
increase; this is due to economy meltdown
•Healthcare-related expenditures:
• Represent 17.8% of U.S. economy
• Equal three times defense spending
• Are greater than the amount Americans spend on food,
housing and transportation combined
> + +
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What is insurance?
•Purchasing “Peace of Mind”
•Pay a premium for protection for everyday and
catastrophic events
•Fixed monthly premium regardless of claims and
utilization
•Number one reason for personal bankruptcy is
catastrophic healthcare costs
•Insurance benefits are as important as salary in
influencing employee loyalty
Source: MetLife’s Study of Employee Benefits Trends,2009
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Relationship between
premium and claims
•20% of the population is responsible for 80% of
healthcare claims
•Pools “spread risk” among many rather than just a few
•Premium dollars are pooled to help pay large claims
•Every group may not have a large claim every year, but
every year groups have large claims
•Healthier population = lower healthcare costs = lower
premiums over time
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Types of plans
•Indemnity plans (aka “Major Medical” or “Hospitalization
Coverage”)
•HMOs
•POS
•PPOs
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Network Coverage
Out-of-network
You Share More of the Cost
No Provider Discounts
You File Claims
Greater Out-of-Pocket Costs
In-network
Receive Highest Level of
Benefits
Access Provider Discounts
Provider Files Claims
Lowest Out-of-Pocket Costs
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How are claims paid?
•You seek service
•Providers bill insurance companies
•Billed amount adjusted for discounts, allowable charges
•Participant may be responsible for part or all of balance
•Largely automated – no human hands
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What happens if the
claim is paid incorrectly?
•Doctors code incorrectly
•Claims are resubmitted for reimbursement
•Claim appeal process
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Explanation of Benefits
(EOBs)
•Shows how your claims have been paid
•Includes:
Amount charged by doctor
Allowable charges
How much was applied to deductible
Coinsurance
Service details
How much you may be responsible for
Online
Download EOB guide now!
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Copay Bucket Doctor and
RX
You never fill the
copay bucket –
copays continue
throughout the plan
year.
Deductible Bucket Inpatient, Outpatient
Surgery, Advanced
Diagnostic
After annual
deductible is paid, the
deductible bucket is
full.
Coinsurance Max Bucket Inpatient, Outpatient Surgery,
Advanced Diagnostic
After deductible is paid, the
insurance company begins
cost sharing with employees at
the coinsurance level until the
maximum is met. When the
coinsurance max is met, the
bucket is full.
Copays, deductibles &
coinsurance maximums
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SELECTING THE RIGHT PLAN
FOR YOUR EMPLOYEES
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How do I compare plans?
Balance of cost & coverage – Two choices
Pay
Lower
Premium
Pay
Higher Out of
Pay
Higher
Premium Pay
Lower Out of
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Your population’s unique
needs
•Life stage: what are their likely current and future
healthcare needs?
•Health
Chronic conditions
Prescription drugs
Wellness
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Employee costs
•Deductibles
•Out-of-pocket expenses
•Cost-sharing (contributions)
•Benefit pay packages
Pay package approach
Pay + benefits approach
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Knowing what’s covered:
Doctor visits
•Doctor visit copays
•Primary care doctors
•Specialists
•Preventive care/wellness
•Services that may not be covered by copays
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Knowing what’s covered:
Lab and x-ray services
•Coverage depends on how/where services are received
Preventive care services
In-office services
Free-standing lab or x-ray facilities
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Knowing what’s covered:
Surgeries & hospital visits
•Pre-authorization
• Inpatient Admit
• ER services
• Penalty
•Deductible
•Coinsurance
•Out-of-pocket coinsurance maximum
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Knowing what’s covered:
Prescription drugs
•Tiered copays
• Generic
• Preferred
• Non-Preferred
•What is a formulary?
•Who creates formularies?
•Why are they important?
•Specialty drugs
•Online pricing tool
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Five pitfalls to avoid
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Pitfall #1: Shopping on
price
•Danger: comparing exclusively on price
•Not all plans are created equal
•Must consider both cost and how your employees are
likely to use the plan
The solution:
Shopping priorities
and price
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Pitfall #2: The rating
game
•“Base” rates vs. actual rates
•Medical underwriting
•Getting a fair renewal
The solution:
Finding the right
– not the lowest –
price
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Pitfall #3: Getting the
whole package
•Price vs. quality
•Customer service
•Advocacy
•Broker relationships and commissions
The solution:
Don’t just buy a
product, look for a
relationship
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Pitfall #4: Uncovering
coverage
•Not all plans are created equal
•Loopholes and limits
•Gaps and exposures
The solution:
Review coverage
documents
thoroughly
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Pitfall #5: “Thank you &
goodbye”
•After the sale support
•Administration
•Enrollment
•Issue resolution
•Customer service
The solution:
Get referrals, and
look for a provider
dedicated to service
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Final Thoughts
•Do your homework
•Seek a trusted resource
•Consider your employees needs
•Consider your ministries resource
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Questions?
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