Transcript Pay or Play Solutions - Allied National Companies

Allied™ Pay or Play Solutions
Cost-effective options for the Employer Shared
Responsibility provisions of the Affordable Care Act
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Allied Pay or Play Solutions
• Employer Shared Responsibility (Pay or Play)
• Impacts, Requirements & Penalties
• Product Solutions for Large Employers
• Sample Cases
• Submissions and Underwriting
Allied National
Home Office - Overland Park, Ks.
2nd generation
family-owned business
Founded 1970
Proprietary systems
Company Culture
Innovation
Stability
Service
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Allied National
Operational Profile
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Underwriting
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Claims Administration
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Policy Service
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Actuarial
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Compliance
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Product Development
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Case Management
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Sales & Marketing
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Legal
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What you need to know and learn to
understand Pay or Play
ACA Pay or Play Regulations and Language:
• What is an applicable large employer?
• What is an FTE? How to count FTEs?
• How do the penalties work?
• PMEC/Skinny Plans/MVP/Narrow Plans
• Affordability
• 2015 rules vs 2016 rules – group size, penalties
• Transition relief rules - All employee test/All FT
employee test
These are the high points -THIS IS NOT
ALL!!!! Expect the rules to change
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For the Individual - Employee
What does ACA mean for
an individual?
1. Individual Mandate says individuals must have health
insurance or pay a penalty.
• Penalty starts at $95 for 2014 then in 2016 escalates to
$695 or 2.5% of taxable income (which ever is greater).
2. Insurance can be employer provided or an individual plan.
Must be qualifying Minimum Essential Coverage.
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For a Business – Employer
What you need to know about
ACA for businesses . . .
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Do I have to offer health
insurance to my employees on
January 1, 2015?
less than 100
more than 100
Based on full-time equivalent employee counts.
Part-timers count!
In 2016, the employer size drops to 50!
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What type of coverage must I offer?
Employer coverage must meet TWO levels
of tests under Section 4980H
“A” test – “The Sledgehammer”
• Must provide Minimum Essential
Coverage to 95% of full-time eligible
employees (70% in 2015)
• The Penalty? $2,000 per full-time eligible
employee less the first 30 (80 in 2015)
• Penalty triggered by employee going to
the Exchange and receiving subsidy
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What type of coverage must I offer?
Employer coverage must meet TWO levels
of test under Section 4980h
“B” test – “The Tackhammer”
• Must provide Minimum Value Coverage
to 95% of employees
• Coverage must be Affordable (no more
than 9.5% of household income).
• The Penalty? $3,000 per employee who
receives subsidized coverage on the
Exchange
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What If I don’t Play?
PENALTY EXAMPLES
Employer with 180 full-time eligible employees
(A) Failure to provide MEC:
$2,000 (180 - 80*) = $200,000 non tax
deductible penalty ($300,000 in 2016!)
(B) Failure to provide Minimum Value
affordable coverage:
$3,000 per employee with subsidized coverage
* less 80 is 2015….less 30 in 2016
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What are an Employer’s Options?
1. Pay the penalty?
2. Find the cheapest way to avoid penalties?
3. Provide a major medical health plan to everyone?
4. Provide an affordable alternative in the middle?
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Allied Pay or Play Solutions
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Creative suite of products to meet any employer’s
needs
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Uses a mix of self-funded and fully insured options
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Low-cost Alternatives
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Meets Current Minimum Essential Coverage (MEC)
and Minimum Value standards
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Four plan levels
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Allied Pay or Play Solutions
Offering four plan levels to manage the expense of this
mandate:
Allied Pay or Play Solutions
Plan Level 1 – Self Funded PMEC
• Preventive Services Only Minimum Essential
Coverage (PMEC)
• Meets MEC requirement and avoids the employer
sledgehammer penalty
• Meets individual mandate and covered employees
avoid that individual penalty
• Lowest cost way to avoid penalties
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Allied Pay or Play Solutions
Plan Level 2 – Fully Insured Limited Benefit Plans
Fixed Indemnity plan on top of PMEC
• Allows employer to provide additional benefits on
top of a PMEC plan
• Employer paid or voluntary
• Benefits for hospitalization, office visits, Rx drugs
Gap Plan
• Supplement for high deductible plans
• Employer paid or voluntary
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Allied Pay or Play Solutions
Plan Level 3 – Self-funded Minimum Value Plans
Allied Minimum Value Plan (MVP)
• Low Cost Narrow MVP plan – one size fits all
• Guaranteed Issue – No Medical Underwriting
• First dollar benefits - $0 deductible with copays
• Eliminates In-Patient, Surgery and Specialty Drugs
• Adds indemnity benefits for In-Patient & Surgery
• Currently Satisfies Minimum Value 60% standard
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Allied Pay or Play Solutions
Plan Level 3 – Self-funded Minimum Value Plans
Allied MediPay Plan
• Comprehensive Major Medical - Controls costs by basing
provider reimbursement on Medicare
• Physicians reimbursed at 125%
• Facilities at 125-200% as selected.
• Lowers monthly costs 10% to 30% below traditional PPO
reimbursement
• Members subject to balance bill
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Allied Pay or Play Solutions
Plan Level 4– Self Funded Traditional Plans
• Allied Funding Advantage Plans
• Premium Advantage – traditional PPO plans
• Provider Freedom – no network, see any provider,
protection from balance bills
• MediPay Plan – no network, Medicare
reimbursement - Employee is responsible for all
balance bills under MediPay
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Sample PMEC Case
Assumptions
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Employer Contribution 100% of PMEC Plan
90% Participation combined required
Type of Risk
Restaurant Chain
FT employees
425
Management - Group Major Medical
75
Penalty Exposure (After tax)
Penalty Exposure per FT employee
PMEC Cost (350 FT employees)
PMEC Cost per employee (annually)
$986,000
$2,817
$210,000
$600
Sample MVP Case
Assumptions
•
75% participation required
Type of Risk
Construction Company
FT Employees
130
Management - Group Major Med
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Penalty Exposure (After tax 2015)
$142,857
Penalty Exposure (After tax 2016)
$285,714
Penalty Exposure per FT Employee (All 2015 -80)
$1,099
Penalty Exposure per FT Employee (All 2016 -30)
$2,857
Minimum Value Plan Participants
Minimum Value Plan Costs (estimate)
Minimum Value Plan Annual Costs - Total
85
$2,400
$204,000
Plan Structures
Fully Insured Structure
• Limited Benefit
• Gap Plans
Self Funded Structures
• Funding Advantage, PMEC, MVP, MediPay
• 12-21 contracts
• Plan run out period ends the last day of month 21
• Refunds calculated in month 22
• Refunds disbursed in month 23
• Monthly accounting summary
• Quarterly claims reports
• Renewal offers on all groups
Claims Payment
Balance Bill Obligations
Provider Freedom
& PPO Plans
• Employee IS NOT responsible for any
balance bill
Medipay, MVP & PMEC
• Employee IS responsible for all balance
bills
ID cards for PMEC/MVP/MediPay will show Medicare reimbursement levels.
Members receive Advocacy help in balance bill situations.
Underwriting Time Frame
Recommended timeline for
• Complete submissions should arrive in Allied
underwriting department not less than 15
to the desired effective date.
• Submissions received on or before the 10th
receive priority consideration.
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Time Frame: Medically
Underwritten Cases
Duration of underwriting determined by:
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Size of the account
Quality and completeness of submission
Availability and cooperation of the employer &
Firm rates in 7-10 days
From submission to case delivered – 14 to 20 days
Shelf life of enrollment form is 40 days – up to 60
recertification
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Time Frame: PMEC - MVP
Duration of underwriting process
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Size of the account
Accuracy of census
Allied National workflow
Firm rates in 3-5 days
7-10 days to complete documentation and issue
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Agent’s Compensation
Funding
Advantage
& MVP
Default 2-6% adjustable as
required
PMEC
10%
Limited Benefit & Gap
TBD
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Our Sales Team
Contact Us
Email or fax data to “Sales”
[email protected]
888-767-7133
Fax: 913-945-4390
Our Team
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Dan Meylan: National Sales Director; 913-945-4253
Bill Ringhofer: Regional Sales Manager; 913-945-4266
Randy Wehner: Sales Manager; 913-945-4267
Matthew Bryon: Account Executive; 913-945-4255
Cheryl Knight: Account Executive; 913-945-4261
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Questions?
Allied National, Inc.
4551 W. 107th St. #100
Overland Park, KS 66207
Allied Sales Support
888-767-7133
www.alliednational.com
[email protected]
twitter.com/alliednational
Fax: 913-945-4396
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