solutions IssUE || september - October 2011
Innovative Health and BeneďŹ t Management
Whereâ€™s the Boost to Getting Healthy? When is a summary More than a summary?
looking to save anyway they Can
the Case for Wellness among Fully-Insured employers
PMS 1585 C 0 M 62.29 Y 98.25 K 0 R 245 G 126 B 37
Smarter is a healthier workforce and guaranteed savings.
Aetna wellness programs actually work. With Aetna Healthy CommitmentsSM, your employees are more likely to choose better health and reduce your costs, guaranteed. • Save $100,000 at renewal1. • Simple, bundled solutions make it easy to choose and implement a wellness program that suits your needs and your budget. • Personalized tools and incentives encourage employee participation, and guarantee 1-2% trend reduction. See the proof and the savings at smarteris.aetna.com/well, or just scan the code. Illustrative only. Average savings for a customer with 1,500 members and average $400 per member per month premium. May not be representative of the experience of all plan sponsors. Underwriting criteria will determine whether specific customers will qualify for this guarantee. This program may not be available in some states for insured products. Check with your local Aetna representative. © 2011 Aetna Inc. Plans offered by Aetna Life Insurance Company. Health insurance plans contain exclusions and limitations. 2011104
Features | Departments 5 Editor and Publisher’s Letter The Institute for HealthCare Consumerism Makes Debut
6 People on the Move 6 Briefs/Innovations • Global Health Medical Travel Programs Available Under Qualified HSAs Through My HSA Rewards • Limeade’s Automated Fulfillment Program Enables Online Redemption of Wellness Incentives at Global eCommerce Leader • Coventry Health Care Joins Forces With Walgreens, Wal-Mart on 2012 Medicare Part D Plan
7 IHC FORUM Save the Date 1 Supplemental Health & 1 Voluntary Benefits Supplemental Health Insurance: A Costeffective Tool to Enhance Employer Benefit Packages As employers face cost challenges as a result of a tough economy where every dollar counts and the volatility of health care reform, increasing numbers are offering voluntary supplemental employee benefits to enhance their health insurance benefits program.
17 Looking to Save Anyway They Can B:11.125”
Just when it appeared the nation was in full economic recovery mode during the first quarter of 2011, the market began a steady decline and leading some economists to fear a double-dip recession.
By Rose Hook
13 Population Health Management
By Todd Callahan
The Case for Wellness Among Fully-insured Employers Fully insured employers (and their brokers) are often reluctant to implement wellness programs because they feel their health insurance premiums are determined more or less by the claims of all the employers in the carrier’s risk pool. That’s usually condensed into the sentence, “I’ll never see the ROI.” By Jack Curtis
15 Rewards & Incentives Where’s the Boost to Getting Healthy If overweight Americans could magically drop their weight back to 1991 levels, it would save our country and our employers $1 trillion a year. But, do employees really want to make those challenging lifestyle changes? Is there a secret ingredient that gets individuals off the sofa and into their walking shoes? By Don Doster
21 Ask the Expert When is a Summary More than a Summary: Agencies Issue Guidance on New Summary of Benefits and Coverage Requirements On Aug. 22, 2011, the Departments of the U.S. Treasury (“Treasury”), Labor (DOL) and Health and Human Services (HHS) (collectively, the “Agencies”) jointly published proposed regulations (“Regulations”) that identify the standards for the uniform explanation of coverage requirement under the Patient Protection and Affordable Care Act of 2010 (ACA).
By John Hickman
24 Who’s Who Profiles 27 Resource Guide/Ad Index
Event The 2012 IHC Forum After two successful conferences in 2011, The Institute for HealthCare Consumerism, formerly known as CDHC Solutions, has confirmed dates for our 2012 conferences: • IHC FORUM East, Cobb Galleria Centre, Atlanta, April 12-13 • IHC FORUM West, Red Rock Resort, Las Vegas, Sept. 6-7 For more information please visit www.theihccforum.com Have something to share? Post a blog or forum on our new website www.theihcc.com. Come be apart of The Institute for HealthCare Consumerism.
Print and Online Key Connect with CDHC experts and community members online at www.TheIHCC.com by looking for the following symbols at the end of each article: blog
WHO’S WHO PROFILE
EMPLOYEE COMMUNICATION & EDUCATION
HSA/HRA/FSA ADMIN & FINANCE
S TOTAL POPULATION HEALTH/WELLNESS
PHARMACY BENEFITS MGMT
POLICY & LEGIS PERSPECTIVE
SUPPLEMENTAL BENEFITS MGMT
TOOLS AND TECHNOLOGY
www.TheIHCC.com I CDHC Solutions™ I September/October 2011
What’s Happening at The Institute
Web Features | Visit www.theihcc.com for instant access to constantly evolving communities. Here are just a few of the latest lessons and perspectives by industry insiders:
The IHC brings you the Collective Voice on Health Care Consumerism via a social networking site that uses a 24/7 virtual, portable format.
Health Plan Communication Your Value-based Benefit Strategy Is as Smart as Your Employees’ Phones By Robert S. Oscar, R.Ph., CEO of RxEOB
Health Decision Support Tools Search for Health Information Going Mobile By Joseph Conn, ModernHealthcare.com
HSA/HRA/FSA Admin & Finance Health Choices and Jobs By Grace-Marie Turner, president, Galen Institute
Medical Travel Making Sense of Health Care Prices By John Goodman, president, National Center for Policy Analysis
Pharmacy Benefit Management Implementation of Medicare Part D, Nondrug Medical Spending for Elderly With Limited Prior Coverage By J. Michael McWilliams, MD, PhD, Alan M. Zaslavsky, PhD and Haiden A. Huskamp, PhD
Regulatory & Compliance IRS Proposes ‘Play or Pay’ Safety Net for Employers; HHS Closer to ‘ Essential Health Benefits’ Rule By Ed Fensholt, Lockton
Blogs | Sharing thought leadership with 70,000+ members. It’s our mission to feature blogs with helpful advice, best practices and solutions that really work. Connect with experts who take pride in learning and staying motivated: Patient Empowerment Why Health Care Reform is Doomed Without It By Maria Hester, M.D., Savvier Health, LLC.
September/October 2011 I CDHC Solutions™ I www.TheIHCC.com
What Health Care Benefits Issues Are You Most Concerned About? Sign up as a free member to join the only networking community for innovative health benefits management. Learn the latest trends. Connect with like-minded professionals in your field. Share your blog, forum or vision on health care consumerism. Visit www.ihcc.com, today. Social Networking | Facebook: Become a Fan of CDHC Solutions Magazine and connect with other CDHC followers, plus receive recent site postings from our wall feeds, which include FORUM incentives and more. LinkedIn: Make sure to join our CDHC Solutions by the Institute for HealthCare Consumerism where you can participate in the latest discussion on CDHPs. TweetTweet: Follow us on Twitter@the_IHC and stay in the constant loop with health care reform news, industry updates and more.
Editor & Publisher
www.ihcc.com VOLUME 7 NO. 5 July/August 2011
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Karen Raudabaugh 404.671.9551 ext. 108 · email@example.com CDHC Solutions ™ Volume 7 Issue 5 Copyright ©2011 by FieldMedia LLC. All rights reserved. CDHC Solutions ™ is a trademark of FieldMedia LLC. CDHC Solutions ™ is published eight times yearly by FieldMedia LLC., 292 South Main Street, Suite 400, Alpharetta, GA 30009. Periodical postage paid at Alpharetta, GA and additional mailing offices.
The Institute for HealthCare Consumerism Makes Debut Having announced the formation of The Institute for HealthCare Consumerism at our CDHC Solutions FORUM West event in Denver on Sept. 15, we have received overwhelmingly positive feedback. Formerly known as CDHC Solutions, visitors to the new website www.theihcc.com have discovered The Institute provides the most comprehensive editorial content focusing on the latest trends in health and benefits management. Our website houses arguably the largest library of articles, white papers, press releases, blogs and case studies to aid employers, brokers, advisors, consultants, TPAs and regional health plan providers to educate themselves and their employees and/or clients about the megatrend of health care consumerism. The website also highlights case studies from the top solution providers in health care. The IHC features regular contributors such as National Center for Policy Analysis President John Goodman and Grace-Marie Turner, the president of the Galen Institute and author of the best-selling book Why ObamaCare is Wrong for America. In addition to these nationally-renown thought leaders, we also showcase our own editorial advisory board chairman Ron Bachman’s commentary and his thoughts about the latest health care trends, PPACA and how it affects the health care consumerism movement. Not only is The Institute your one-stop shop to learn from the industry’s top thought leaders and solution providers, we offer a free membership allowing you to participate and contribute to The Institute. As a free member, you can contribute with either a blog or post your own case studies. As a member, you will be able to add comments on articles posted on The Institute website. Coming Jan. 1, 2012, the website will offer even more member services allowing you to connect virtually with fellow members of the Institute, thought leaders, bloggers and members of the elite League of Leaders. The website also will feature HealthCare Consumerism University, a virtual campus experience allowing members to attend classes, webinars and podcasts offered by prominent thought leaders in the health care industry. Another perk of becoming a member of The Institute is a discount to our awardwinning IHC FORUM conference series. IHC FORUM East will be held in Atlanta on April 12-13 at the Cobb Galleria Centre, and IHC FORUM West is slated for Sept. 6-7 at the Red Rock Resort in Las Vegas. So become a member of The Institute today. Borrowing a phrase from a leading credit card company, ‘Membership has its privileges.’ Sincerely,
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People on the move
People on the Move RedBrick Health, a pioneer and leader in consumer health engagement technology for employers and communities, announced Daniel Ryan has joined the company as chief executive officer (CEO). Ryan is charged with driving the company’s growth, expanding upon an impressive run of tripledigit growth over each of the past three years. Both Ryan and RedBrick Founder and President Kyle Rolfing, will serve on RedBrick’s Board of Directors. Ryan was most recently president and CEO at Secure Computing, a leader in enterprise security solutions. Prior to Secure Computing, Ryan served as president and chief operating officer at Stellent, a leading enterprise content management software company, and later as senior vice president of enterprise content management products at Oracle, which acquired Stellent. Ryan joined Stellent from Foglight Software, an innovator in e-commerce and application performance management where he headed marketing, product management, and business development. Lockton Benefit Group of Lockton Companies, the world’s largest privately held independent insurance brokerage firm, has expanded its team with
Henry Albrecht, CEO of Limeade Inc., announced that Limeade’s innovative corporate wellness platform now includes an automated incentive fulfillment program that enables wellness program enrollees to earn Amazon.com Gift Cards. Limeade is an online corporate wellness platform that builds happy, healthy, high-performance workforces. The new gift card incentive fulfillment program provides employers and health plans using the Limeade platform with a tightly-integrated, seamless means of providing immediate incentives for program participants—without time-consuming and costly physical cards and mailings. Amazon.com Gift Cards earned through the program never expire and can be redeemed towards millions of items at Amazon.com. “We’re thrilled to be using Amazon.com Gift Cards to provide employers and health plans with an incentive option. This is one more example of Limeade’s hyper-flexible incentive management approach. Health plans and employers are increasingly demanding fun, sexy ways to attract and engage wellness participants,” Albrecht said.
Global Health Medical Travel Programs Available Under Qualified HSAs Through My HSA Rewards Global Health Voyager Inc., a full-service web-based medical tourism facilitator, announced My HSA Rewards as the first member to join its HSA affiliate program. Medical travel programs are now available through the only HSA cash rewards program offered by My HSA Rewards, designed to engage individuals, employers and insurance agents in a new program to help save more money on health care. According to the U.S. Department of the Treasury, HSAs were created in 2003 so that individuals covered by high-deductible health plans could receive tax-preferred treatment of money saved for medical expenses. “For the first time, HSA account holders have the opportunity to take advantage of a medical travel benefit and access high quality health care September/October 2011 I CDHC Solutions™ I www.TheIHCC.com
Colibrium Direct LLC, a leading provider of telesales business process outsourcing for health insurance plans, announced Mark Poling took over the role of chief executive fficer. Poling was one of the original founders of Colibrium Direct in June, 2010 and also is a Principal of Colibrium Partners LLC, which he co-founded in 2005. Poling succeeded CEO Brian Will, who will be moving on to focus on other business ventures. David Fee will continue as vice president of sales. Colibrium Partners recently received the Microsoft Health Plan Partner of the year award for 2011 and was awarded Celent’s VIP in 2010. People on the Move, continued on page 8
Limeade » Global Health Medical Travel » Humana
Limeade’s Automated Fulfillment Program Enables Online Redemption of Wellness Incentives at Global eCommerce Leader
the addition of Orlando M. Neal as Director of Pharmacy Analytics. Neal’s primary role is to provide national leadership in the Pharmacy Benefits Management area. Neal is responsible for strategic pharmacy benefits consulting and management of key national relationships with Lockton’s pharmacy benefit providers. Supporting Lockton’s sales professionals and leading client engagements also are part of Neal’s ongoing role. Neal holds a Masters degree in Business Administration and a Bachelor of Arts in Mathematics/Actuarial Science and Economics.
services at significant savings virtually anywhere in the world,” said Sanders McConnell, president of Healthy Rebates Inc. and sponsor of My HSA Rewards. “Medical travel promotes the advantages of personal choice, an underpinning of HSAs, and we look forward to continue expanding the opportunities for our members.” An annual census by America’s Health Insurance Plans (AHIP) of U.S. health insurance carriers shows the number of people covered by HSAs totaled 11.4 million in January 2011—up from 10 million in January 2010, 8.0 million in January 2009, and 6.1 million in January 2008. “Our relationship with My HSA Rewards marks the first time that HSAs can be used for medical travel expenses,” said Ali Moussavi, president and CEO of Global Health Voyager. “The incredible growth of HSAs is testimony to the American appetite for exercising individual preferences when it comes to health care services. Medical travel is certainly an example, and we anticipate that account holders will take advantage of this new offering.”
Humana Announces Agreement to Acquire Arcadian Management Services Humana Inc. announced that it has signed an agreement to acquire Arcadian Management Services, an Oakland, Calif.-based Medicare Advantage HMO with approximately 64,000 members in 15 U.S. states. Terms were not disclosed. Arcadian Management Services was founded in 1996 and is dedicated to improving the health of its members by providing access to high-quality, cost-effective health care. Most Arcadian members reside in small or medium-sized communities across the U.S. Arcadian’s 2010 revenue was $622 million. The transaction is subject to both federal and state regulatory approvals and is expected to close in late 2011. Humana’s acquisition of Arcadian is not expected to materially impact its financial earnings guidance for the year ending Dec. 31, 2011. Innovations, continued on page 8
The Collective Voice on Innovative Health & Benefit Management
SAVE THE DATE for the 2012 FORUMS
foruM EAST 2012 April 12-13
Cobb Galleria Center
foruM WEST 2012 September 6-7
LAS VEGAS Red Rock Resort
Visit www.theihcc.com to register for FOrUM and sign up for membership at The Institute at www.theihcc.com FieldMedia LLC is the parent company to CDHC Solutions magazine, EmployersWeb.com, IHC FORUM and The Institute for HealthCare Consumerism. 292 South Main St., Ste 400, Alpharetta, GA 30009
People on the move
People on the Move, continued from page 6
American CareSource Holdings (the “Company”) announced that its Board of Directors has appointed William J. Simpson as president and chief operating officer. Simpson joined the Company’s Board of Directors in November 2010 and was appointed COO in December 2010. In addition, Kenn S. George’s role as Chairman of the Company’s Board of Directors has been expanded to include chief executive officer. The appointments follow the acceptance by the Board of Directors of David S. Boone’s resignation from his positions with the Company. Simpson is the former president, CEO and Director of Intrepid USA Healthcare Inc. In addition, he has served on multiple boards, including Genezen Healthcare, where he was chairman. In addition Simpson had held a number of executive management positions including executive vice president and chief operating officer at LifeCare, executive vice president and COO at Specialty Healthcare Services, executive vice president of operations at Intensiva Healthcare Corporation, president and COO at Ameristat Mobile Medical Services, president of Epic Healthcare Services, and vice president of American Medical International. Shared Health, a leader in the health information technology (HIT) industry, announced Michael Heekin has joined the company as chief executive officer (CEO). Heekin, the founding chief operating officer of WebMD, is set to lead the company’s technology and services expansion. Heekin was recently appointed by Governor Rick Scott to serve on Florida’s Government Efficiency Task Force and also worked as an advisor to Governor Jeb Bush in Florida’s
WebMD Health Services Highlights Innovative Approach to Condition Management at Forum 11 WebMD Health Services, a leading provider of health and benefits management solutions and a subsidiary of WebMD Health Corp., unveiled a solution-oriented approach to condition management that leverages the company’s technology strength, engagement expertise, and clinical knowledge. “Individuals coping with acute and chronic health conditions—such as obesity, diabetes, asthma, heart disease, and others—can have a dramatic impact on overall population health care costs and productivity,” said Dr. Rajni Aneja, chief medical officer at WebMD Health Services. Dr. Aneja presented the first implementation of WebMD Health Services’ condition management approach, an Obesity Management program, during a special demonstration at Forum 11. Studies show that obese individuals have 43 percent higher medical costs1 and miss 3.7 more days of work per year than people of average weight. WebMD’s Obesity Management solution combines claims, HRA and self-referral information to identify high-risk individuals and engage them using telephonic and digital health coaches, online resources, and progress tracking. “Leveraging our strong consumer brand and in-house engagement services agency, our solutions consistently deliver engagement rates that are among the highest in the industry—ensuring that our condition and lifestyle management solutions help individuals improve their health and have a real impact on our clients’ bottom lines,” Dr. Aneja said. WebMD’s Obesity Management program includes: health coaching, September/October 2011 I CDHC Solutions™ I www.cdhcsolutionsmag.com
Integrated Healthcare Strategies, a health care consulting firm providing alignment, engagement and performance enhancement solutions, is honored to announce that esteemed health care industry leader, William F. Jessee, MD, FACMPE, FACPM has joined the firm as senior vice president and senior advisor. Dr. Jessee joined Integrated Healthcare Strategies in October following his retirement as the president and chief executive officer of the Medical Group Management Association (MGMA), the nation’s leading voice for group medical practice, where he presided for 12 years. In addition to his role with Integrated Healthcare Strategies, Dr. Jessee also holds an academic appointment as Clinical Professor of Health Systems, Policy and Management at the University of Colorado School of Public Health. Medicaid Health Plans of America (MHPA) welcomes Michelle Martin as Director of their recently established Center for Best Practices. Martin will oversee the Center in its mission to improve quality and access to care
Global ecommerce leader » Global Health Medical Travel » Humana
Innovations, continued from page 6
effort to move toward electronic health records. He has served on the Board of Shared Health since 2007. Shared Health products include Shared Health® Clinical Xchange®—A platform that supports the delivery of Shared Health’s solutions, including data exchange and interoperability, data transformation and normalization, clinical guidance and analytics, with security—and privacy. In addition the company offers ePrescribe and additional health information technologies that give clinicians point of care information.
online digital health assistant, integrated progress tracking, and engagement. WebMD’s Obesity Management solution is currently available. The next program to deliver this innovative new condition management experience will be launched in December for diabetes.
Leadership Directories Introduces Health Focus Database To Build Connections in Growing, Complex U.S. Health Care Industry Leadership Directories announced the launch of Leadership Health Focus. This innovative and comprehensive database features valuable, up-to-date profile and contact information for more than 150,000 key decision makers and 8,000 leading organizations across all major sectors of the U.S. health care system, including government, corporate health, hospital systems, and non-profits. The U.S. health care system is vast, complex and undergoing dramatic change. To help navigate this large and increasingly interconnected industry, Health Focus is a powerful resource that allows users to quickly identify and gain insightful knowledge about the most important people and organizations. Updated daily, Health Focus provides accurate, current profile and contact information for the key leaders and organizations across all major health care sectors, including: federal, state, and local government departments and agencies, corporate health sector, including pharmaceutical and biotech manufacturers, medical supplies distributors, managed care companies, and health insurance providers, Hospitals and health systems, including health information exchanges and assisted living centers, Non-profits, including research organizations, medical schools, trade associations, and foundations.
for Medicaid beneficiaries through in-depth research and dissemination of health plans’ clinical and operational best practices. Specifically, Martin will engage the senior leadership of MHPA’s member and non-member health plans—including CEOs, CFOs and Chief Medical Officers—to develop collaborative strategies aimed at improving the health outcomes of plan members. Under her stewardship, the Center also will partner with other research teams to develop special programs, publications and rigorous studies designed to target health problems and identify innovative databased solutions. A Michigan native, Martin earned her B.A. in economics from Albion College and her J.D. from Wayne State University Law School. Anthem Blue Cross and Blue Shield in Missouri announced that Steve Martenet was been named president, effective Sept. 1. Martenet is an Anthem veteran and brings deep experience to his new role. He currently serves as president and general manager of Specialty business for Anthem’s parent company. Martenet has been with the company for almost 17 years and previously served as president of Anthem Blue Cross and Blue Shield in Wisconsin. Martenet graduated cum laude from Bowling Green State University in Ohio. He has completed executive education courses at Indiana University’s Kelley School of Business, Northwestern’s Kellogg School of Business and the University of Chicago’s Graduate School of Business. Conner Strong & Buckelew, a leading insurance, risk management and employee benefits brokerage and consulting firm, announced that Franz Wagner has been named senior vice president, major accounts, senior account executive. Wagner brings more than 25 years of professional
experience to Conner Strong & Buckelew. Serving as senior account executive, his primary responsibility will be to direct account services for large and strategic business relationships of Conner Strong & Buckelew. In this role, he will manage and design property and casualty insurance programs for larger, more complex accounts. Prior to Conner Strong & Buckelew, Wagner was vice president at The Graham Company where he managed many of the agency’s largest health care, construction and aviation accounts, among others. Wagner graduated from the United States Naval Academy with a BS in Mechanical Engineering and is a licensed professional engineer. Conner Strong & Buckelew, a leading insurance, risk management and employee benefits brokerage and consulting firm, announced that Kristine Klepper, CEBS, has been named senior vice president, employee benefits practice leader. Klepper brings more than 20 years of professional experience to Conner Strong & Buckelew. As a Practice Leader, Klepper will oversee a team of benefit consultants as well as provide account services for larger, more strategic accounts. Her primary client service responsibilities include strategic planning, benefit evaluations and financial analysis. She works with clients to set short and long term strategies to address health care costs, health care reform, and promoting health management and productivity within their organization. Prior to Conner Strong & Buckelew, Klepper was senior vice president and local market leader for Aon Hewitt for 15 years where she was an account manager for several large and mid-size private sector and public sector employers. Prior to joining Aon Hewitt, she spent seven years in health and welfare consulting at the Apex Management Group and Miller Mason & Dickenson. Klepper earned a Bachelor of Business Administration from The College of Insurance in New York City.
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Individual coverage underwritten and offered by American Family Life Assurance Company of Columbus. In New York, coverage underwritten and offered by American Family Life Assurance Company of New York. Some policies may be available as group policies. Group coverage underwritten and offered by Continental American Insurance Company. Policies may not be available in all states. Aflac pays cash benefits direct to the insured, unless assigned. Aflac processes most claims in an average of four days. For Continental American Insurance Company, the average is five days. NAD1115
By Rose Hook Burnham Benefits Insurance Services
Supplemental Health Benefits
Supplemental Health Insurance: A Cost-effective Tool to Enhance Employer Benefits Packages
s employers face cost challenges as a result of a tough economy where every dollar counts and the volatility of health care reform, increasing numbers are offering voluntary supplemental employee benefits to enhance their health insurance benefits program. Supplemental health benefits are just what they sound like: insurance benefits intended to supplement primary health coverage with additional protection. Some examples include: supplemental life and accidental death and dismemberment insurance, short-term and longterm disability insurance and critical illness insurance.
Enhancing Benefit Programs with Supplemental Coverage Rising employee benefit costs have forced many employers to curtail additional spending for their health insurance program. As a result, such employers have turned to voluntary employee-purchase options as an enhancement to their benefits packages without impacting their bottom line. Approximately 30 to 40 percent of employers currently include some type of supplemental insurance in their benefit packages. Supplemental plans also are attractive to many employees eager for the “guaranteed” protection additional coverage provides. For example, an employee with significant health issues can purchase supplemental life insurance up to a certain amount without any medical underwriting (“guaranteed issue”). Also, an employee who wants to ensure he or she receives some level of income while short- or long-term disabled can generally purchase such insurance without any medical questionnaires at reasonable rates. On the open market, achieving both of these scenarios would most likely be difficult or even unattainable.
Helping Employees Understand Supplemental Benefits Some employees will decline the coverage because they see it as one more bite out of their paychecks. However, the incentive for those employees willing to pay a few extra dollars to shelter themselves and their families from significant financial risk should they become sick, injured or even die, often outweighs the associated cost of the premium. Thus, educating employees that the coverage is offered as “guaranteed issue” and/or without any medical questionnaire requirements is vital and should be received as very favorable to them.
Making Education and Enrollment Simple Employers who offer supplemental insurance often utilize printed literature, webinars, call centers and on-site enrollment meetings to educate their employees about the benefits of the additional coverage. Such communication ensures employees are aware of the full spectrum of
benefits available to them and educates them on how supplemental health benefits work and why they’re so valuable. There are a variety of enrollment pathways to make the process easy and convenient. One of the most successful enrollment processes is a face-to-face meeting with a professional enroller who can answer specific questions and discuss the individual needs with each employee. Web portals, call centers and mobile education and marketing also are fastgrowing options. Many employers also offer mid plan-year enrollment kick-offs to offer the additional exposure and education necessary to achieve higher participation levels. As employees get a firmer grasp on what supplemental insurance can provide, they’re less likely to dismiss coverage. Properly communicating and educating plan opportunity, affordability and exposure reduction help ease many people’s initial reluctance to sign up.
The Future of Supplemental Coverage Growing numbers of employers are discovering supplemental health benefits as a way to round out a solid benefits package for recruitment and retention purposes, enhancing core health benefits, and containing overall costs. The win/win nature of the plans for both employers and employees is likely to further their popularity in the foreseeable future. As employers explore the value of supplemental insurance for their organization, it’s important to determine employee interest, cost savings, ease of administration and using supplemental health benefits as a tool to help support employee recruitment and retention. This can often be done through collecting general employee feedback, as well as printed and online employee benefit surveys. Knowing what employees really want and how to best deliver, gives every dollar spent greater impact. The supplemental health insurance market is likely to grow and evolve in the coming years, and competition will continue to bring new options to the table and keep rates competitive. The good news is that they already offer an attractive road for employers who want to provide a broader range of benefits within the rigid financial constraints of operating in a challenging economic environment. Rose Hook is a senior account executive at Burnham Benefits Insurance Services. She is responsible for new business development and managing accounts in the Los Angeles metropolitan area. Hook serves clients’ consulting needs in Health & Welfare and 401(k) Retirement Plans. Hook is experienced in plan design, negotiation, funding, and implementation of both local and nationwide managed care programs, benefit program analysis and planning strategic cost efficiency. She has been instrumental in designing plans, which fit the particular needs of her clients and ensuring a smooth implementation and renewal process. For more information, visit www.BurnhamBenefits.com.
www.TheIHCC.com I CDHC Solutions™ I September/October 2011
By Jack Curtis » CEO Corporate Health Partners
Population Health Management
The Case for Wellness Among Fully-insured Employers
ully insured employers (and their brokers) are often reluctant to implement wellness programs because they feel their health insurance premiums are determined more or less by the claims of all the employers in the carrier’s risk pool. That’s usually condensed into the sentence, “I’ll never see the ROI.” Conventional wisdom says that any savings from a healthier workforce fall to the insurer’s bottom line, not the employer’s. It is true that some of the savings from an effective wellness program will benefit the insurer. However, employers should consider the rest of that story. It might be logical to think that it should not be employers, but insurers, that should invest in wellness to improve their profits. However, effective wellness programs would add 5 percent to the health plan cost and make the health plan uncompetitive versus other insurers without serious wellness programming. Therefore, insurers feel their customers would jump ship long before a wellness investment would pay off. Therefore, most carriers use wellness only as a loyalty program—not for reducing health care costs. They offer some “free” virtual tools like a wellness portal, an online Health Risk Assessment or call-in health coaching. These tools are relatively inexpensive window dressings that insurers can offer to make their health plans more appealing without making their pricing uncompetitive. Unfortunately one characteristic of all tools is they don’t accomplish anything unless someone uses them. Utilization of insurers’ virtual wellness tools among fully-insured employers is practically nil. Since most fully-insured employers do not get serious wellness programming from carriers, what is the business case for running a program on your own dime? Let’s first look at several factors impacting the direct cost of health insurance: Even though the smallest fully-insured employers’ premiums are based entirely on the experience of the whole risk pool, carriers watch each employer’s experience, which can be so much worse than the pool that it becomes virtually impossible to shop plans. When they reach that point, employers are at the mercy of the insurer and must accept whatever increase they’re dealt each year—if they continue to offer health insurance. I’ve heard of increases in excess of 50 percent. Employers in this scenario are the best candidates to utilize the health insurance exchanges when they become available. As the number of covered employees increases, there is a point at which carriers start to increasingly adjust premiums according to each employer’s claims experience. Therefore, employers with an unhealthy population and higher claims will receive higher premium increases than the rest of the pool. As the number of employees increase, there is a point at which carriers adjust premiums entirely based on the employer’s own claims experience. If an employer’s claims come in higher than the insurer predicted and budgeted in the premiums quoted, they will make it up and more with the following year’s premium increases.
Even though carriers are not investing in serious wellness for their customer base as a whole, some are reportedly beginning to give their customers 2-5 percent discounts off the nominal increase in premiums to customers that have wellness programs they feel are effective. So wellness WILL still help control the direct cost of health insurance. However, the biggest pay-off for wellness is NOT the direct cost of health insurance. That’s just the tip of the iceberg. Here’s the reasoning: The indirect costs of poor health—such as absenteeism, workers compensation, short- and long-term disability and presenteeism—are three times the direct costs of health insurance. (See the landmark study reported in 2004 in the Harvard Business Review). The smaller the firm, the health and productivity of each person become even more important. Taken to the limit, if the sole employee in a one-person firm goes down, it’s out of business. Wellness programs improve morale. Happy workers are more productive. Michael O’Donnell found that culture is the single most important determinant of the success of a wellness program, and culture is much quicker and easier to improve in smaller organizations. Employers need wellness for the same reason that they need benefits—to attract and retain the best employees. Wellness is a terrific way to say that you care, which improves retention and decreases the cost of turnover. In fact one of the primary reasons Vanderbilt University implemented a wellness program for the university and medical center was to reduce the high cost of turnover—with outstanding results. In fact they won the prestigious C. Everett Koop National Health Award in 2008. Here’s the bottom line conversation that often occurs when I speak with fully-insured employers: Employer: “I can’t afford a wellness program. I can just barely afford health insurance.” Me: “I understand. Then why don’t you drop your health insurance benefits? You cannot sustain these cost increases.” Employer: “Are you crazy? How could I attract and retain good employees without health insurance?” Me: “You’re right. If you offer health insurance, you are in the health management business, whether you like it or not. Now, the question is— are you going to manage health reactively or proactively? Employers who manage health reactively are the ones who can barely afford insurance anymore. In fact, they may soon be out of business. Many employers have already been driven out of the business, or out of the country by unsustainable health plan increases.” Jack Curtis is founder and CEO of Corporate Health Partners (CHP), a full-service wellness company that designs and manages corporate health and wellness programs across the nation. CHP recruits a local wellness coach for every client worksite—to implement best practices, coach the client’s wellness team and deliver year round programming. Our coaches can deliver highly effective face-to-face health coaching that’s complimented by weekly touch points. CHP’s systematic approach and handson focus weaves wellness into the culture and achieves lasting, measurable results. www.TheIHCC.com I CDHC Solutions™ I September/October 2011
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By Don Doster » CEO gBehavior
Rewards and Incentives
Where’s the Boost to Getting Healthy?
f overweight Americans could magically drop their weight back to recognizable to peers. Used in this way, incentives will have a powerful 1991 levels, it would save our country and our employers $1 trillion a behavioral effect. And speaking of choosing—employers have a choice, too. They can year. But do employees really want to make those challenging lifestyle changes? Is there a secret ingredient that gets individuals off the sofa and pay now for a wellness solution and potentially prevent catastrophic diseases among their employees in the future, or they also can choose to into their walking shoes? avoid the “wellness” and pay big During a recent wellness claims now and later. Wellness program launch, a skeptical Motivation depends on the individual. We are incentive programs bring hope employee stated, “I’m not all motivated differently and what energizes one and turn hope into reality; interested in losing weight. My for the employer; and husband loves me just like I am.” person may not provide change for another. The savings quality of life, better health However, the employee and tangible rewards for the enrolled in our wellness incentive most effective wellness programs are the ones employee. program. Reason—she realized where employees/members can earn incentives A final example: Polly saw that by exercising three times her 2010 health assessment a week and losing at least a that they choose—incentives that are tangible profile and knew changes pound a week, she would earn needed to be made. Polly enough reward points to ‘pay’ and recognizable to peers. started immediately making for her kids’ Christmas gifts. The personal lifestyle changes by clincher—she could select the gifts she wanted from among thousands and thousands of choices. By the eating healthier and exercising. Recently Polly had her checkup with her time the holidays rolled around, she had lost 70 pounds, was completely physician and the news was outstanding. off her diabetes medication, and was thrilled. n Weight reduced by 71 pounds—IMPRESSIVE “I already knew I needed to lose weight, but education was not n Blood pressure decreased from 144/84 to 122/68—SPECTACULAR enough to make me actually do it. Choosing was the key. Getting to select n Blood sugar lowered from 120 to 89—GREAT gift for my kids motivated me. At first, losing weight was a secondary goal. n Good cholesterol up 11 points—WOW But now, I look and feel so much better, that I just want to keep on going.” n Bad cholesterol down 9 points—STUPENDOUS People generally do not change their behavior without good reasons. n HgbA1c blood test results went from 7.5 percent to 5.1 percent— Most of the time good health is not a sufficient reason. In a perfect world, AWESOME the prospect of a healthier, longer life should be enough to prompt us to change. Not so. Research shows that among heart attack patients—change These results are wonderful; there is more good news. Polly was is a life and death matter—90 percent do not change their unhealthy bothered with extreme arthritis prior to her success. She was taking habits, not even when the doctor makes it a requirement. prescription medication twice a day. Now she is not on any arthritis The Power of Choice One company previously tested a wellness medication. Her physician says if she loses 30 more pounds, she can program that paid employees $50 cash to complete a health risk further reduce her other medications. assessment, a biometric screening and a disease management program. “I feel so much better and much healthier.” Polly stated. “I want to The engagement was low—around 15 percent. After implementing our be here a lot longer. I feel like I am taking the necessary steps to make wellness incentive program with $50 in reward points, the employee that happen.” participation soared to 70 percent. Reason: Cash does not provide a On the road to wellness, getting started is the key and incentives tangible reward with trophy value. provide that boost. But the actual reward of getting healthier and feeling One company added that its incentive program did not work. better is the sustaining motivation. This program provided running shoes to employees who responded to a wellness challenge. Very few people participated because only a few Don Doster is CEO of gBehavior, which is located in Atlanta. He specializes in the employees were actually interested in having a new pair of running shoes. design and implementation of wellness incentive programs. The company’s complete wellness platform, based on years of experience and proven results, combines all Motivation depends on the individual. We are all motivated differently necessary aspects of behavior change to meet employer business objectives and to and what energizes one person may not provide change for another. The drive improved employee health through tangible rewards that capitalize on the most effective wellness programs are the ones where employees/members power of choice. can earn incentives that they choose—incentives that are tangible and For more information, visit www.gBehavior.com or call 888-949-0541.
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Looking to Save Anyway They Can
ust when it appeared the nation was in full economic recovery mode during the first quarter of 2011, the market began a steady decline and leading some economists to fear a double-dip recession.
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or $5,800 for a family and are non Since December 2009, the With the more detailed claims taxable. official start of the “Great Recession,” The employer, who sees the more than 15 million jobs have been information available under a selfmajority of their cost going to lost. funded plan, an employer becomes sponsoring an employee health The nation has witnessed a plan, also benefits from a CDHP. double-digit unemployment rate, and more empowered to focus on According to a multi-year government-sponsored programs, study by Aetna, employers that such as the American Recovery solutions including targeted replaced their traditional health and Reinvestment Plan, passed in benefits plans with a CDHP saved 2009, expected to produce three to wellness programs. $21.5 million over a five-year four million jobs and stimulate the period for every 10,000 enrollees. economy has failed to produce. It has This study focused on health had the opposite effect, as job losses care claims and utilization in Family Foundation and The Health Research & have increased, resulting in more Americans losing their employer-sponsored Educational Trust Employer Survey, 69 percent traditional HMO/PPO plans versus consumerof mid- to large-size firms offered health benefits directed plans administers. The study also health care coverage. Next to salary, health care is the biggest this year, an increase from 60 percent during showed enrollees in a CDHP were more engaged than an employee enrolled in a traditional cost for employers, who continue to battle a last year’s survey. Given the continued instability of the coverage plan. declining bottom line while maintaining the best “The rising cost of health care has been a nation’s economy, it is surprising the percentage benefits possible for their employees. Even individuals with job security are of companies continuing to offer employer- concern for companies for many years now,” facing uncertainty, as many small employers sponsored health benefits has increased during said Mark Bertolini, president and CEO of Aetna. “We have shown that by working together are contemplating ending health care benefits the “Great Recession.” One possibility is an increase in consumer- to engage consumers in their own care and and paying a fine as stipulated by the Patient directed health plans, more specifically the by giving them easy-to-understand tools and Protection and Affordable Care Act (PPACA). According to a survey by Towers Watson, number of health savings accounts (HSA) or actionable information, we can help companies only 7.2 percent of medium to large-size health reimbursement accounts (HRA) linked keep their employees healthy and save money.” While a CDHP is a win/win situation for employers are looking to drop employee health with a high-deductible health plan has continued both employee and employer, a CDHP is still to gain acceptability. care benefits all together. According to the Kaiser report, 23 percent far below the traditional health plans. PPOs The survey also said that more employers plan on terminating heath care benefits once the of mid- to large-size firms began offering a are offered to nearly 50 percents of all-sized government-mandated exchanges [either by the CDHP with an HDHP. Of the largest employers— firms offering employer-sponsored health plans. state or federal government] begin Jan. 1, 2014. with more than 1,000 employees—surveyed, 41 Much like a CDHP, PPOs are linked to a highHowever, there are other employers percent offered a CDHP. The survey also added deductible, but do not offer the employee as who believe terminating health care benefits that total enrollment of employees in a CDHP much responsibility or control as an accountcould send a wrong message to their employee has risen to 17 percent of the nation’s entire based health plan. While companies are spending more money population. Therefore the majority of employers workforce in 2011. This is a huge growth seeing plan on staying in the health care provider as only 4 percent of the American workforce on education tools to teach their employees the benefits of CDHPs, perhaps the biggest participated in a CDHP in 2005. business. “Health plans with HSAs offer protection engagement tool has been the sluggish economy. “Employers are reluctant to lose control over a key employee benefit,” said Tracy and a tax-free way to invest—all at a cost that is It’s the employee’s hard-earned dollars. They get Watts, a partner in Mercer’s Washington, D.C., usually less than what someone would pay for to choose how they use it. “HSAs encourage employees to share the office. “But beyond that, once you consider the a traditional plan,” said Roy Ramthun, founder penalty, the loss of tax savings, and grossing and president of HSA Consulting Services. “For responsibility—and the rewards,” said Dennis up employee income so they can purchase families with about $1,500 in annual medical Triplett CEO UMB Healthcare Services. “With comparable coverage through an exchange, for expenses, an HSA can often save them more a comprehensive plan grounded in prevention, employees can take charge of their health many employers dropping coverage may not than $6,000 a year.” In a stagnant economy, everyone is care, educating themselves about preventive equate to savings.” Insurance offered by employers is the being forced to be better educated consumers, care, generic drugs, disease management, and leading source of health coverage in the United including health care. An HSA allows the wellness programs. Research shows, knowing States, providing benefits to about 150 million consumers more control on how their medical how to make better choices leads to better dollars are spent. The consumer also can health, and that affects not only the health of people. According to a report by The Kaiser contribute up to $2,900 a year as an individual employees, but also the health of the business.” 18
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Another encouragement for employers to drop their traditional health plan and move to a full CDHP is the PPACA. According to the Keiser survey, 90 percent of employers believe the health care law will increase the company’s health care benefit costs. The increased cost in employer-sponsored health plans created by the PPACA and the individual mandate requiring everyone to have health care, gives companies incentives to encourage their employees to participate in a CDHP. According to the Mercer study, a CDHP costs about 15 percent less than an HMO or PPO. “Employers see them as a way to provide more value to employees while at the same time managing cost,” said Beth Umland, Mercer’s director of health and benefits research. In Southeast Michigan, an area rocked by the recession where companies have closed and the unemployment rate is more than 16 percent, struggling employers are continuing to provide employer-sponsored health plans according to an employer survey conducted by McGraw Wentworth, Michigan’s largest employee group benefit brokerage/consulting firm. Surveying 470 of the region’s mid-size employers, those with employee population from 100 to 10,000, revealed that only 7 percent of companies are likely to stop offering employee benefits. The survey also revealed an increase in the number of firms offering CDHPs. “Organizations that manage cost increases to the lowest levels are putting decisionmaking regarding personal health and health care purchasing in the hands of the consumer,” said Rebecca McLaughlan, managing director, McGraw Wentworth. “Employers can hold health care benefit costs in check by engaging employees. For example, a leading consumer strategy is three-tier prescription drug copay programs, where employees choose from either a generic, formulary brand or non-formulary brand drug,” The survey indicated employers offering a CDHP this year rose to 27 percent compared to 19 percent in 2009. Five percent of companies surveyed offered CDHPs as the only plan option. The survey also revealed that traditional HMOs remain a good cost competitive option due to innovative, wellness-centered plan designs. “Mid-sized employers are considering the impact of health reform but few indicate they will
move to eliminate group health plan coverage,” added Julie Truskowski, account director with McGraw Wentworth and survey leader. “Employers are looking closely at the ‘play or pay’ aspects of health reform and the status of their health plans. Two things are certain: Change is under way and employers will need to make some strategic decisions before 2014 to accommodate health care reform mandates. “In today’s economy and with health reform under way, the survey analysis provides Michigan employers with an objective, statistically valid tool for benchmarking plan designs and evaluating cost sharing strategies for 2011 and beyond”
THE PPACA is Not all Bad Although employers see the PPACA as the main culprit in aiding the escalation of the cost of health care, one aspect of the health care law is trying to help curb health care cost by eliminating abuse and fraud in a broken system. There are four reasons for the increasing cost of health care: The top areas found to be responsible for the greatest amount of waste in
the health care system are: n Administrative system inefficiencies n Provider inefficiencies and errors n System inefficiencies n Fraud According to a report by the Associated Press in early September, nationwide law enforcement crackdown has charged 91 people—including doctors and other medical professionals—with participating in Medicare fraud schemes involving $295 million in false billing. Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius said that 70 people were charged in indictments and 21 others were charged earlier, beginning Aug. 24. Charges were filed in Baton Rouge, La.; Brooklyn, N.Y.; Chicago, Dallas, Detroit, Houston; Los Angeles and Miami. At a news conference, the attorney general said that those arrested are “jeopardizing the integrity of our health care system.” Sebelius called the law enforcement initiative “a powerful warning to those who would try to defraud taxpayers and Medicare beneficiaries. www.TheIHCC.com I CDHC Solutions™ I September/October 2011
and abuse in the health Eleven of the people “Medicare and Medicaid fraud, waste, fraud care system is to avoid having to charged were doctors, three were see a health care provider. nurses and 10 were licensed and abuse cost taxpayers billions of Many proactive health professionals. employers are not waiting on More than half the dollars each year and put beneficiaries’ the government to stamp out defendants—46—and $160 health and welfare at risk…” fraud and abuse in the health million of the total in phony care system and focusing on claims announced came from establishing wellness programs South Florida, an area leading for their employee population. the nation in Medicare fraud. A healthier workforce produces fewer trips While the arrests are a start, it is only a the Patient Protection and Affordable Care Act drop in the bucket to the amount of claims abuse (Affordable Care Act or ACA) further heighten to the doctor thus cutting back on insurance claims and producing a healthier bottom line. the need for robust oversight.” in the system. While employees are taking more Through the efforts of the Office of The country spends and estimated $2 trillion on health care, however according Inspector General (OIG), employing all oversight responsibility abut their health care spend, other to a study by the National Health Care Anti- and enforcements tools available and with the companies like change:healthcare are helping Fraud Association, $68 billion of that is lost on cooperation of the HHS and the Department of by creating a “Transparency Messenger,” which fraudulent claims. Fraud accounts for 19 percent Justice, there has been a rise in the number of proactively alerts employees when they have an opportunity to save money on routine care, of the estimated $600 to $800 billion in waste federal heath care fraud prosecutions. Over the past fiscal year, OIG has opened procedures and prescriptions. in the nation’s health care system. After an easy implementation and training The bulk of this amount is from fraudulent more than 1,700 health care fraud investigations. Medicare claims to kickbacks between doctors Additionally there have been 900 criminal and period, change:healthcare’s Transparency prescribing unnecessary medicine because of a civil actions and more than $3 billion in expected Messenger will help the clients’ employees better understand and manage their individual health investigative recoveries in 2010. partnership with a pharmaceutical firm. The PPACA also has provided the federal care expenses. Due to the lack of transparency, dishonest Unified Group Services, which offers a medical providers can charge extra to the government more power in fighting fraud patient’s health plan. Since most health care and abuse by offering $350 million in fraud range of administrative and wellness products to consumers struggle to understand their medical enforcement funding for the next 10 years. A more than 22,000 members enrolled in preferred provider organization (PPO) or high-deductible bill, excess charges are rarely discovered. third of that was added to the 2011 budget. The Obama administration also has made it plans, rolled out the change:healthcare’s The health care provider is charged an excess a point to crack down on fraudulent health care Transparency Messenger to its internal employees amount, thus increasing the cost of health care. “Although there is no precise measure of claims, and the 85 percent increase in heath care in August and started offering the program to its the magnitude of health care fraud, we know fraud prosecutions compared to the first eight clients in early September. “As TPAs consolidate and compete for marthat it is a serious problem that demands an months of 2010 is proof of the commitment. Larger health insurance companies and ket share, Unified continues to differentiate itself aggressive response,” Inspector General of the U.S. Department of Health & Human Services third party administrators also have bolstered and stay ahead of the curve by implementing Daniel Levinson told the U.S. Senate Finance their budgets to fight health care fraud, technologies that make the lives of employees and Committee in mid May. “Medicare and Medicaid purchasing software that seeks out anomalies their families easier,” said Howard McLure, CEO fraud, waste, and abuse cost taxpayers billions of in health care claims that could identify possible of change:healthcare. “Transparency Messenger offers companies the ability to proactively arm dollars each year and put beneficiaries’ health fraudulent claims. However, this software is pricey and insurer employees with the information they need to and welfare at risk. The impact of these losses and risks is magnified by the growing number investigative units are usually small and do not become smarter health care consumers—ultiof people served by these programs and the have the budget to actively investigate all of the mately reducing overall health care costs and significantly impacting the bottom line.” increased strain on federal and state budgets. fraudulent claims cases. However the only 100 percent way to avoid Moreover, new and expanded programs under
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Ask The Expert
By John Hickman » Partner Alston + Bird LLP
When Is a Summary More than a Summary: Agencies Issue Guidance on the New Summary of Benefits and Coverage (SBC) Requirement
n Aug. 22, 2011, the Departments of the U.S. Treasury (“Treasury”), Labor (DOL) and Health and Human Services (HHS) (collectively, the “Agencies”) jointly published proposed regulations (“Regulations”) that identify the standards for the uniform explanation of coverage requirement under the Patient Protection and Affordable Care Act of 2010 (ACA). The ACA directs the Agencies to develop standards for a uniform explanation of benefits and coverage (“Summary of Benefits Coverage” or SBC) to be provided by group health plans and health insurance issuers offering group or individual health insurance to enrollees. The long-awaited and much-anticipated Regulations propose the standards that will govern who provides an SBC, who receives an SBC, how the SBC is provided, when the SBC is provided and the contents of the SBC. In addition, the Agencies also published a draft template for the SBC, with more than 30 pages of instructions, sample language for completing the template and a uniform glossary of terms used in health insurance coverage, such as “deductible” and “copay,” as required by the Regulations. The SBC requirement is statutorily effective March 23, 2012. Presumably, this means that the requirements apply to enrollments—including new enrollees, mid-year or special enrollments and annual enrollments—after that date. The standards set forth in the Regulations for completing and distributing an SBC will likely have a significant impact on each group health plan’s enrollment procedures and materials and, unless the effective date set forth in the statute is extended by the final rules, there is little time to prepare. Health insurers and group health plan sponsors should begin analyzing the standards now! The following is an overview of the who, what, when, where and how of SBC compliance, as set forth in the Regulations, the draft template and the uniform glossary.
Who Must Provide the SBC? The Regulations obligate the group health plan (including the plan administrator) and, if applicable, the health insurance issuer offering coverage in connection with a group health plan (i.e., if the plan is fully insured) to provide the SBC in accordance with the standards described below. Thus, if the group health plan is self-insured, the obligation to provide an SBC lies solely with the plan administrator. If the plan is fully insured, the obligation to timely send the SBC lies with both the plan administrator and the health insurer. The Regulations clarify that a responsible party may rely on another party to send an SBC, but only if a timely SBC is actually sent. In many cases, the health insurer may not have all of the information necessary to fulfill the SBC requirements (e.g., insurers of a multiple-option plan may not have census information on employees enrolled in other options or in eligible individuals who are not enrolled). Thus, some level of involvement and coordination by the employer plan sponsor will be required.
Who Must Receive an SBC? Basically, all individuals who are eligible to enroll in the group health plan are entitled to receive the SBC. The Regulations indicate that a “participant”
and “beneficiary” as defined in ERISA Sections 3(7) and 3(8) are entitled to an SBC in accordance with the standards discussed herein. However, don’t let the terms “participant” and “beneficiary” mislead you into believing that the SBC is provided only to those actually enrolled in the plan; the terms “participant” and “beneficiary” are defined broadly by ERISA and include not only those who are currently enrolled in the plan (i.e., covered employees and covered dependents), but anyone who is eligible to enroll. Thus, employees (including former employees) and dependents eligible to enroll in the group health plan are entitled to receive an SBC. The SBC must be incorporated into the plan’s enrollment process.
When Must the SBC be Provided? Generally, the SBC is provided to a participant or beneficiary at three different times: n At any enrollment, n Upon request, and n When there is a material modification in the information. It also must be provided by a health insurer to a plan at certain times. Newly Eligible Participants and Beneficiaries (Other than Special Enrollment) Individuals who first become eligible for coverage on or after March 23, 2012, other than during a special enrollment period, must receive the SBC in connection with any written (or electronic) enrollment materials distributed by the plan as part of the initial enrollment process. If the plan does not distribute written or electronic enrollment materials as part of the initial enrollment process, the plan must distribute the SBC no later than the first day on which the individual is otherwise eligible to enroll. The SBC must generally be provided with respect to each benefit package offered by the plan for which the newly eligible individual is eligible. If any of the information required to be in the SBC changes before the first day of coverage (e.g., prior to the end of the waiting period), then an updated SBC must be provided prior to the first day of coverage. Newly Eligible Participants and Beneficiaries (Special Enrollment) Individuals enrolling pursuant a HIPAA special enrollment on or after March 23, 2012, must receive the SBC within seven days of the request for enrollment. The SBC must be provided with respect to each benefit package option for which the special enrollee is eligible. If any of the information required to be in the SBC changes before the first day of coverage (e.g., prior to the effective date of coverage), then an updated SBC must be provided prior to the first day of coverage. Annual Enrollment (Renewal) The SBC must be provided as part of the plan’s annual enrollment process, even if the participants and beneficiaries have already received an www.TheIHCC.com I CDHC Solutions™ I September/October 2011
Ask The Expert SBC as part of the initial enrollment process. According to the Regulations, if eligible individuals must enroll in writing (or electronically), the SBC must be provided with the written or electronic annual enrollment materials that are provided. If annual enrollment is automatic, the SBC must be provided no later than 30 days prior to the first day of coverage for the new plan year. Unlike the initial enrollment and special enrollment periods, only an SBC for the benefit package in which the individual is currently enrolled must be provided during annual enrollment, even if the covered individual is eligible for other benefit package options. Nevertheless, the covered individual is entitled to receive a copy of the SBC for the other benefit package options for which he is eligible upon request (see “Upon Request by a Participant or Beneficiary” below for a more detailed discussion). If any of the information required to be in the SBC changes before the first day of coverage (e.g., between the date the SBC is provided in connection with annual enrollment and the first day of the next plan year), then an updated SBC must be provided prior to the first day of coverage. Upon Request by a Participant or Beneficiary The SBC must be provided to an eligible individual in connection with a request for information about a plan or policy as soon as practical, but no later than seven days following the request. Material Modifications Where a material modification is made to the terms of the plan that would impact the information in the most recently distributed SBC, and such change is made other than in connection with “renewal” (i.e., it is not a change required to be reflected in the SBC provided during annual enrollment), then notice of the modification must be provided at least 60 days prior to the effective date of the change. The preamble to the Regulations reflects that the mid-year notice can either be a separate notice describing the change or an updated SBC. Otherwise, the format of the notice and the manner in which it must be delivered must comply with the format and delivery requirements of the SBC.
How Must the SBC be Delivered? An SBC provided by a plan or health insurer to a participant or beneficiary may be provided in paper form. Alternatively, for plans and issuers subject to ERISA (plans sponsored by private employers) and/or the Internal Revenue Code (e.g., church plans), the SBC may be provided electronically if the requirements of DOL’s electronic disclosure safe harbor are met. Nonfederal governmental plans may comply with either ERISA’s electronic disclosure safe harbor requirements or, alternatively, the requirements applicable to insurers in the individual market. Generally, the SBC must be a stand-alone document; however, the Agencies request comments as to whether the SBC may be sent with the plan’s summary plan description if the SBC is intact and provided at the front of the SPD. The Regulations further propose that a single SBC may be sent to the address at which all individuals to whom the SBC must be sent reside. However, if any eligible dependent’s address is different than the eligible employee’s address, a separate SBC must be provided to the beneficiary residing at a separate address. For an SBC provided by an issuer to a plan, the SBC may be provided in paper form or electronically. For electronic forms, the format must be readily accessible by the plan, and the SBC must be provided in paper form upon request.
September/October 2011 I CDHC Solutions™ I www.TheIHCC.com
What are the Format and Content Requirements for an SBC? An SBC must satisfy the following format requirements: n Four double-sided pages (i.e., a total of eight printed pages, front and back) n No less than 12-point font (and the instructions to the draft template reflect that the font must be Times New Roman). An SBC must satisfy the following content requirements: n Uniform definitions of standard insurance terms and medical terms, so that consumers may compare health coverage and understand the terms of (or exceptions to) their coverage; n A description of the coverage, including cost sharing, for each category of benefits identified by the Departments; n The exceptions, reductions and limitations on coverage; n The cost-sharing provisions of the coverage, including deductible, co-insurance and copayment obligations; n The renewability and continuation of coverage provisions; Coverage Examples which illustrate common benefits scenarios and related cost-sharing based on recognized clinical practice guidelines: n A statement about whether the plan provides minimum essential coverage, and whether the plan’s or coverage’s share of the total allowed costs of benefits provided under the plan or coverage meets applicable requirements (this information does not have to be provided until on or after Jan. 1, 2014); n A statement that the SBC is only a summary and that the plan document, policy or certificate of insurance should be consulted to determine the governing contractual provisions of the coverage; n A contact number to call with questions and an Internet address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained; n For plans and issuers that maintain more than one network of providers, an Internet address (or similar contact information) for obtaining a list of network providers; n For plans and issuers that maintain a prescription drug formulary, an Internet address where an individual may find more information about the prescription drug coverage under the plan or coverage; n An Internet address where an individual may review and obtain the uniform glossary; and n Premiums (or cost of coverage for self-insured group health plans). In addition, if at least 10 percent of the population in the county are literate only in a particular non-English language and speak English less than “very well,” as determined by the American Community Survey data published by the United States Census Bureau, then each SBC sent to a recipient with an address in that county must include a one-sentence statement in that non-English language about the availability of language services provided by the plan.
What Happens if I Don’t Comply? Potential penalties for failure to comply with the SBC requirement are severe, including agency-induced fines of up to $1,000 for each failure to distribute an SBC and the self-reported excise tax applicable to group health plans (other than governmental plans) under Section 4980D of the Internal Revenue Code. The Department of Labor (which has enforcement authority over ERISA plans) has indicated that it will issue separate enforcement penalty regulations in the near future.
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Health Care Reform? Health Reform Navigator—Your complete Health Reform Information Center. It provides an aggregation and “point & click” navigation to information regarding the Patient Protection and Affordable Care Act (PPACA).
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The Health Reform Navigator organizes massive information into a simple searchable format. It provides easy access to actual legislative language, regulations from DOL, HHS, and the Treasury, multiple industry and think tank time lines, and industry surveys on what employers think of reform. You can stay alert to HOT TOPICs, read independent legal and consulting observations, and much more. There are even more than 50 government produced videos and multiple private conference video links. “The Health Reform Navigator is a great new tool for our readers to get answers to questions that make their jobs easier.”
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A combined $400 value, subscribers can get instant access and a one-year subscription for $99 or $9.99 for a monthly subscription. CDHC Solutions also is offering a one-year subscription for free by signing up for pre-conference event sponsored by Center for Health Transformation. For details please see www.cdhcsolutionsforum.com.
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Who’s Who Profiles
Solutions to help your innovative health and benefit programs. Population Health and Wellness
Population Health and Wellness
79 River St. Suite 302 Montpelier, VT 05602 802.223.5686 firstname.lastname@example.org www.tomypath.com PATH is a dynamic health and productivity management program provider committed to redefining worksite wellness. PATH helps companies develop a comprehensive and cost-effective approach to reduce risks and manage healthcare costs. Our programs have earned unprecedented rates of success as demonstrated by the best sustained participation rate in the industry, and dramatic reductions in the cost of insurance claims and rates of insurance premiums for our clients.
“Based on more than 20 years of R&D, PATH is differentiated by its fun, fresh approach and easy-to-implement programs that have been lauded by both organizations and by program participants. PATH’s programs offer a suite of wellness strategies that integrate seamlessly with other wellness providers and existing employee benefits to deliver one co-branded Web-based platform for users.” – Gillian Pieper, Co-Founder and Vice President, Research and Health Promotion, PATH tools and Technology
Liazon was founded in 2007 to tackle the myriad problems inherent in employee benefits for small and mid-sized employers. Liazon’s retail employee benefits solutions give employers a cost-saving defined contribution strategy for all benefits. Liazon’s Benefits Exchange™ is the online store where employees find, learn about and purchase health care and other insurance products.
Liazon 737 Main Street, Suite 200 Buffalo, NY 716.803.6190 708 Third Avenue New York, NY 212.209.3836 www.liazon.com
“Liazon’s Bright Choices Benefits Exchange is the online store where employees shop for their benefits. It brings an exciting new retail model to employee benefits that empowers benefits consumers and saves employers money. Think of it as the ‘amazon.com’ for employee benefits.” — Ashok Subramanian, Co-founder and CEO, Liazon
September/October 2011 I CDHC Solutions™ I www.TheIHCC.com
Tools and Technology
Benefit Software Inc. Benefit Software Inc. (BSI) is the leader in client satisfaction when it comes to helping 212 Cottage Grove Avenue organizations meet important benefits Santa Barbara, CA 93101 communications challenges for today’s diverse 800-533-1388 workforce. Offering web-based enrollment www.bsiweb.com solutions, web-based or printed Total Rewards email@example.com Statements, and PC-based Statement software, BSI helps thousands of organizations achieve complex enrollment and communications goals. With over thirty years of experience supporting mid-size to Fortune 500 businesses, BSI has gained insights into solving the most challenging benefits administration and communications challenges. “If you can imagine a benefits enrollment or a benefits communication solution that will help your organization motivate and educate employees then Benefit Software can build that solution for you. We have 30 years of experience in delivering best-of-breed employee focused communications solutions. We look forward to helping you.” — William Smith III, Head of Sales, Benefits Software
Who’s Who Profiles
Access these profiles online at www.TheIHCC.com and www.EmployersWeb.com HSA/HRA/FSA Technology: Administration & Management
HSA/HRA/FSA Technology: Administration & Management
TSYS Healthcare®, provides end-toTSYS Healthcare end strategic payment solutions for 612.338.3871 consumer directed healthcare. We www.tsys.com/solutions/healthcare partner with benefits administrators, firstname.lastname@example.org financial institutions and health plans and software providers to navigate all aspects of HSAs, HRAs, FSAs, cash reimbursements and lines of credit. TSYS Healthcare cards offer participants the security they expect along with the ability to conveniently access funds from multiple accounts and manage their benefits payments with simplified single-card access. Clients and partners benefit from simplified processes, reduced paperwork and cost savings that contribute to improved return on investment.
“We built the TSYS Healthcare platform to meet the market demand for reliable, configurable and intelligent solutions. Understanding the dynamic U.S. Healthcare market, our customers rely on our option-driven system to prepare them for the future. “ — Trey Jinks, Group Executive, TSYS Healthcare
302 Fellowship Road, Suite 100 Mount Laurel, NJ 08054 Internal Sales Support: 888.868.3539 (FLEX), option 4 Proposals and Marketing Inquiries: email@example.com www.flex125.com Established in 1998, AmeriFlex is an independent benefits administrator providing technology-based, consumer-driven benefits and compliance solutions. n AmeriFlex
Convenience Card® Consolidated FSA/HRA/HSA/CRA Debit Card Platform n AmeriFlex Convenience Sleeve Consolidated FSA/HRA/HSA Healthcare Payment Solution n AmeriFlex Convenience Portal WebBased System for Streamlined Administration of CDHC Plans
Enterprise Class, Web-Based Solution for COBRA Administration n ePOP Instant POP Plan Online Document Ordering n Invoice Manager Paperless, Automated System for Group Claim Activity and Funding Administration
“At AmeriFlex, we are constantly looking for new ways to bring innovative and cost-effective payment solutions to the market in order to improve efficiency and simplify the delivery of healthcare products and services to all stakeholders.” — William Short, President & CEO, AmeriFlex
HSA / HRA / FSA Administration and Finance
Evolution1, Inc. 952.908.9056 www.evolution1.com firstname.lastname@example.org
Evolution1 and its Partners serve more than seven million consumers, making it the nation’s largest electronic payment, on-premise and cloud computing healthcare solution that administers reimbursement accounts, including HSAs, HRAs, FSAs, VEBAs, Wellness and Transit Plans. It is the only solution that meets more than 1,200 unique plan designs, provides innovative auto-substantiation technologies, simplifies user experience, and automates workflow for Partners, employers, and consumers. It does all this on one technology platform comprised of Lighthouse1™, PayDirect®, the Benny® Prepaid Benefits Card, Lighthouse1 OneCard™ and integrated web portals. Evolution1 and its Partners are dedicated to delivering value, reducing costs and simplifying the business of healthcare.
“The combination of our innovative products will further our leadership position in a rapidly changing healthcare market. Together with our Partners we are committed to reducing costs and simplifying the business of healthcare.” — Jeff Young Chairman and CEO, Evolution1
www.TheIHCC.com I CDHC Solutions™ I September/October 2011
Who’s Who Profiles
Access these profiles online at www.TheIHCC.com and www.EmployersWeb.com HSA/HRA/FSA Technology: Administration & Management
DataPath, Inc., is one of nation’s largest providers of CDH solutions specializing in account-based administration systems.
1601 WestPark Drive, Suite 9 Little Rock, AR 72204 501.296.9990 www.dpath.com
Since 1984, service providers using DataPath systems have provided administrative solutions for over 1 million participants of FSA, HRA, HSA, and COBRA. DataPath is the only solutions provider to design and deliver a full Suite of systems for handling 125, 105, 132, COBRA, HSAs, Credit and Debit Cards all delivered to account holders through a single Internet portal, myRSC.com.
“With the significant changes in healthcare today, our software solutions allow users to create custom plans for clients that benefit both the employer and employee. Not only have we created a single platform for all systems with myRSC.com, with the integration of our mySourceCard Debit Card at Wal-Mart and other retailers, our clients are able to offer a hassle-free solution with 100% compliance.” ®
The AHIP Center for Insurance Education and Professional Development has offered educational programs for more than 50 years to professionals like you.
AHIP Center for Insurance Education and professional development 601 Pennsylvania Ave., NW South Building, Suite 500 Washington, D.C. 20004 800.509.4422 www.AHIPInsuranceEducation.org
With more content online, including overall health insurance, reform implementation, LTC, DI, and more, the Center will help you learn, achieve, and succeed.
September/October 2011 I CDHC Solutions™ I www.TheIHCC.com
Supplemental Health Benefits
Employer Direct Healthcare (EDHC), Employer Direct Healthcare™ is the next-generation healthcare 7320 N. Mopac EXPY, Suite 203 solution designed to transform the Austin, Texas 78731 way self-funded health plans purchase email@example.com healthcare for their members. EDHC brings together the highest quality 888.241.8537 health care providers to offer www.employerdirecthealthcare.com services directly to the employer through its leading network, National Surgery Network (NSN). Due to its extensive provider network, NSN can offer employers 30-50% savings on planned medical procedures, potentially reducing total plan cost by 6-10%. EDHC is expanding its networks to include diagnostic, imaging, oncology, and more. EDHC is a privately held company headquartered in Austin, Texas.
“The most important issue facing self-funded health plans today is rising costs. Employers can, and should be a catalyst for change in making their health plans more effective. When I bring together high quality providers and self-funded employers, everybody wins. Employers are able to take control of their healthcare expenditures, offer the highest quality care and pass savings on to their employees.” – Ken Erickson, CEO, Employer Direct Healthcare™ Pharmaceutical Benefits Management
Envision Pharmaceutical Services, Envision Pharmeceutical Inc is a full service pharmacy benefits Services, Inc. management company that delivers! John Ewell, EVP Marketing We deliver because our business 925.487.3266 model is based on transparency www.envisionrx.com and full disclosure, guaranteeing firstname.lastname@example.org 100% pass through pricing of all pharmaceutical manufacturer rebates and administrative fees at the point-of-sale. Additionally, our affiliate, Envision Insurance Company, is a national Prescription Drug Plan which enables us to offer a variety of solutions for your retirees. Envision is truly a “different” PBM!
“Envision is pleased to be recognized by its clients surveyed by the Pharmacy Benefits Management Institute for three consecutive years as the top performer in virtually every category evaluated. This solidifies our leadership position in providing transparency and full disclosure to the PBM marketplace while continuing to find innovative solutions.” — Kevin M. Nagle, President & CEO, Envision Pharmaceutical Services/Rx Options
Who’s Who Profiles
Solutions to help your innovative health and benefit programs. Effective print and online opportunity to put your company, its solutions, and your chief sales executive in front of 60,000 print and online prospects. How do you make your company and its solutions accessible to more than 60,000 health care benefits decision-makers, generate leads, and do so cost effectively? By participating in the industry’s only online, member-based networking community!
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New Customer Online Market Impact Program
FieldMedia has developed a special online-only offer to ¡help you create a leadership presence on our member-based Web communities—CDHC Solutions Online and EmployersWeb.com Online—and help you generate sales leads, gain leadership presence, and connect you to our buyers and members.
Take advantage of our innovative online Who’s Who in Consumer-Directed Health Care profiles and receive the complete bonus package including lead-generating eblasts. Call your FM account rep 404.671.9551 or email at email@example.com. Check out the active online Who’s Who Profiles at www.TheIHCC.com.
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IHC Solutions FORUM East/West....................7
IHC About the Institute................................16
Benefits Software....................................... 26
Liazon.................................................. 20, 26
Best Buy.................................................... 14
Bravo Wellness......................................... 12
CDHC Solutions Call for Content..................22
UnitedHealthCare.......................... Back Cover
Health Reform Navigator.............................25
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Brent Macy firstname.lastname@example.org · ext. 103 Vice President of Business Development
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Engaging consumers to make informed health care decisions
UnitedHealthcare’s industry-leading consumer-driven health (CDH) plans were designed to get employees on the path to good health with improved lifestyle habits and use of the health care system. That’s why our plans offer: • 100% preventive coverage and personalized messaging based on individual health care needs • Easy-to-use resources for employees, including treatment cost estimators, Quicken HealthSM Expense Tracker, and Health Care LaneSM to help members understand and maximize their health care benefits • Banking through our own OptumHealth Bank, Member of the FDIC, oﬀering integrated access to account balances and a debit card that makes payments easier Tools like these help employees become active in their own health care decisions. We also oﬀer the employer ready-to-use tools to implement and successfully maintain its consumer-driven health plans.
For more information on UnitedHealthcare’s CDH plans, visit uhctogether.com/CDH or call 1.866.438.5651.
©2011 United HealthCare Services, Inc. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by or through UnitedHealthcare Insurance Company, United HealthCare Services, Inc. or their affiliates. Health plan coverage provided by or through a UnitedHealthcare company. UHCEW506202-001