TEXAS HOUSING ASSOCIATION
Jan 11, 2016
TEXAS HOUSING ASSOCIATION
• Indemnity• Preferred Provider Organizations (PPO)• Health Maintenance Organization (HMO)• Consumer Driven Health Plans• HRA, HSA, RRA• Improved Provider Cost Transparency• Wellness programs • Healthy Initiative Programs
Historical Overview of Benefit Plans & Health System
12.411.2%Pennsylvania
10.111.3%Michigan
11.512.0%Ohio
19.313.9%New York
12.814.2%Illinois
8.715.7%US
300.414.5%New Jersey
9.117.5%Georgia
36.118.8%California
17.819.6%Florida
22.924.6%Texas
Population in Millions
Percent
Location
Source: Wall Street Journal Politics & Economics December 21, 2006
Uninsured Population in large States
Understanding Insurance
• What Affects Cost?
– Plan Design– Utilization– Group Demographics
Who is enrolled in what plan?
55.2%
37.90%
5.80%0.90%
7.0%3.2%
0.0%0.1%3.3%
7.3%
89.3% 89.8%
0%
25%
50%
75%
100%
PPO HMO/POS/EPO CDHP FFS
National Texas Central TX
Plan Design
• Plan Design/Utilization– Deductible– Co-pay– Coinsurance– Out-of-pocket Maximum– Prescription Drugs– Network Steerage
Utilization
• Utilization & Review – Large Case Management– Disease Management– Hospital Surgical Utilization Review– Clinical Treatment Protocols – Health Coaches– Web Based Self Help Educational Tools
Health Care/Cost Management Components 2005-2007
2005-2006 2006-2007 2007-2008
Absorb Cost Increases 33% Absorb Cost Increases 39% Offer Health Risk Appraisal 13%
Increase Premium Contributions
25% Increase Premium Contributions
22% Disease Management Through Health Plan
11%
Increase Deductibles 22% Increase Deductibles 20% Employee Information on Provider Quality
8%
Increase Copays & Coinsurance
20% Increase Copays & Coinsurance
19% Behavior Change Programs Through Health Plan
8%
Offer Programs to Reduce Obesity
7%
Absorb Cost Increases 7%
Increase Premium Contributions
6%
Increase Copays & Coinsurance
6%
Disease Management Through Vendor
5%
Offer Personal Health Records
4%
Large Claims
• Effect of Large Claims
– 2007• 20% Of Claimants Account For 80% Of All Claims
Cost
– Often <2% of Claimants Account For 25-30% Of All Claims
How Does A Consumer Driven Health Plan work with an HSA or HRA?
• Insurance Protection (PPO)Insurance Protection provides comprehensive coverage and security
• Higher DeductibleCoverage starts above higher “deductible” to encourage prudent spending
• Integrated Savings AccountIntegrated Savings Accounts are for member to “use or keep” how they see
fit
Insurance Protection
Insurance Protection
HRA Insurance Protection
Plan D
$300
Health Reimbursement Account RRA
$$$$
One Plan
$750 Deductible
$4,000 OOP
80/50
MAC A 10/35
Debit Card procedures will be established for HRA balances that may be accessed for time of service eligible healthcare services
Money can be used to offset the cost of dependent care coverage
Unlike Flex Dollars, HRA monies are owned by the employer and roll from year to year
Plan A
Plan D
$300 Deductible
$2,500 OOP
80/50
MAC A 10/35
$300$350
Health Reimbursement Account RRA
$$$$
Two Plans
$750 Deductible
$4,000 OOP
80/50
MAC A 10/35
Payroll Deductions would need to be established for buy up plans
Debit Card procedures will be established for HRA balances that may be accessed for time of service eligible healthcare services
Money can be used to offset the cost of dependent care coverage
Unlike Flex Dollars, HRA monies are owned by the employer and roll from year to year
Plan A
Plan C
Plan B
$0 Deductible
$3,000 OOP
90/10 Hospital
80/50
MAC A 10/35
$200$265$325
$$$$
Group Individual Choice Health Plan
$750 Deductible
$4,000 OOP
80/50
MAC A 10/35
$500 Deductible
$2,500 OOP
80/50
MAC A 10/35
Payroll Deductions would need to be established for buy up plans
Debit Card procedures will be established for HRA balances that may be accessed for time of service eligible healthcare services
Health Reimbursement Account Retiree Reimbursement Account
Section 125 Flex & HRA
Flexible Spending Accounts Direct Management of Flex–Medical and Dependent–Debit Card & Paper–Direct Deposit–Recurring Expense–Grace Period Coordination
Health Reimbursement Account
Direct Management of HRA –Medical Contributions–Eligible Medical Services–Dental Contributions –Eligible Dental Services–Vision Contributions –Eligible Vision Services–Medicare Part B Premiums–Medicare Supplement/Advantage Premiums
Health Savings Account
Health Savings AccountExante is Bank Trustee –Medical Contributions –Eligible Medical Services–Dental Contributions–Eligible Dental Services–Vision Contributions –Eligible Vision Services–Medicare Part B Premiums–Medicare Supplement/Advantage Premiums
Prescription Drugs
Prescription Metrics
Prescription 2007 % Retail Prescriptions 91.6%
% Mail Prescriptions 8.4%
Biotech Specialty 14.8%
Member Cost Share 30.5%
% Generic Filled 54.07%
% Brand Filled 45.26%
% Biotech Specialty Filled .34%
% of Specialty $ to Total Rx $ 12.51%
With health care costs on the rise, the use of generic medicines is an easy and effective way to save money.
Here’s why:
Generics are reviewed by the U.S. Food and Drug Administration (FDA) for safety and efficacy and are manufactured under the strict standards that apply to brand-name drugs
Generic drugs create competition, which keeps prices down
Research shows that plan participants can save an average of 30% to 80% when they fill their prescriptions with a generic instead of a brand-name medicine
Why Generics?
• Quantity Dispensed• Administrative Fee• Dispensing Fee• Rebate• Formulary• Extended Release Medications costing more than
standard version (anti-depressants, anti-cholesterol, calcium channel blockers, hypertensive agents and sedative hypnotics)
Prescription Transparency
Copay Steerage
Generic $10
Name Brand $38
MAC A
If a brand name drug is dispensed and a generic equivalent drug exists, the Covered Person pays the difference between the brand name and generic price in addition to the appropriate copayment for the brand name.
Mail Order 2 or 2.5 of retail copay
Biotech $80
Wellness
Focus on Wellness is rapidly becoming part of the employer, group health plan and community landscape.
Major benefit of a healthier workforce is reduced
healthcare cost
Other benefits include enhanced workforce productivity, reduce absenteeism and fewer work-related injuries.
Investing in the Health and Well-being of employees
Early Diagnosis and Intervention
Medical Management Disease Management
Large Case Management
Treatment Compliance
Integration of Healthcare Components
Claim Cost Management
Health / Wellness Promotion
Consumer Education (Mail-Outs)
E-Tools
Personal Health Record
$150 Incentive
Healthy Population Acute Chronic Catastrophic
D2Hawkeye
Prescription Claims
Medical Claims
Lab Values
HRA
Medical Management Resource Tool
HEALTHY INITIATIVES INTERVENTION
Healthy Population
Chronic CatastrophicAcute
Wellness Material
Wellness Material
Wellness Materials
Wellness Materials
3 Health Coach Calls
5 Health Coach Calls
36 Health Coach Calls
52 Health Coach Calls
Provider Provider Provider
Reinsurance Reinsurance
BeWellat TML
Activity Duration Points MON. TUES. WED. THUR. FRI. SAT. SUN TOTAL Brisk Walk OR Jog 1 mile / daily 2
Aerobics / Bike Riding 30 min. / daily 2
Weight Training 30 min. / daily 2
Recreational Sports 60 min. / daily 2
House Cleaning/Yard Work (3 hours) Weekly 2 max XXX XXX XXX XXX XXX XXX XXX
Stretching 20 min. / daily 1
Drink Water 48 oz./daily 1
Low Fat Intake OR Low Calorie Intake < 45 g. / daily 2,200 Calories
1
Fruits/Veggies 4 servings
Daily 2
Limit 2 Caffeine drinks Daily 1
Sleep 7 hrs / nightly 1
Person al Quality Time Reading/Mediation
30min/daily 1
Perfect Attendance Quarterly 5 max XXX XXX XXX XXX XXX XXX XXX
Limit 1.5 hrs TV/Non -work Computer Daily 1
Limit 1 alcohol drink per day/7 weekly Weekly 3 max XXX XXX XXX XXX XXX XXX XXX
Nicotine Abstinence Weekly 3 max XXX XXX XXX XXX XXX XXX XXX
Brown Bag Session Attendance per session Quarterly
3 per session
Routine Biometric Screening
Power Points
_ Health Risk Appraisal Annually 25 _ Routine Physical Annually 25 _ Colo -Rectal Exam (50 yrs & older) Annually 25 _ Mammogram Annually 25 _ PSA test Annually 25 _ PAP test Annually 25 _ Cholesterol Screen Annually 25 _ Osteoporosis Screen Annually 25 _ Blood Glucose Screen Annually 25 _ EKG Annually 25 _ Digital Rectal Exam Annually 25 _ Bone Density Screening Annually 25
Total: [Wellness Points] WEEKLY TOTAL:
[Wellness Points + Power Points] ANNUAL TOTAL :
BeWellatTMLMaintenance Program
1. Create a Wellness Committee & Establish a worksite Mission Statement recognizing employee health and wellness as being important to the long-term success and well being of the organization.
2. Pre- and post-surveying of employees, suggestion/comments box on wellness, ideas/contests. Wellness on the worksite is best when it is fun!
3. Establish a physical activity program at the worksite (map and measure walking paths in and around the area surrounding the worksite).
4. Encourage healthy foods at worksite meetings and in vending machines.
5. Research and post local wellness initiatives that are occurring in the community.
6. Create a wellness calendar that highlights organized activities for the month. Events must be planned in advance and should tie into community programs, physical activity sponsored by programs, and national programs.
Wellness in the Workplace
Start Slow;Stay Steady-
You WIN!F I
N I
S H
Employee Education
New Hire Enrollment
Education is Key….
Health Fairs: Onsite lab services, Contests
Open Enrollment Education Meetings: Conduct presentations and provide education to employee population
Brown Bag Lunch: Employee Assistance Program or other resource
1. Stress2. Finances3. Depression4. Nutrition5. Exercise6. Nutrition
Wellness Committee
Employee Communication: Assist with payroll stuffers, posters, etc.
PEBA
Retirees
• Baby Boomers are retiring and living longer• Generation X’s retiring earlier and starting
second career• Benefit Options [ For under 65 and over 65]
• Employer Definition of Retiree- Accordance with Existing Retirement Program (TMRS)- Under 65 & Over 65, Time of Service, Definitions- Develop Sample Employer Policy and Procedures/or
Ordinances• GASB-Support-Actuarial Service-Strategies
Retiree concerns are one of the biggest challenges faced by Employers
Retiree Solutions
• Comprehensive Medical Plan Option• Medical Plan Option
– Plan Subsidy / Employer Funding• Voluntary• Contributory• Mandatory
• Under 65 and over 65Retiree Benefits– Dental– Vision– Life
• Retiree Reimbursement Accounts
Retiree Benefits
TML IEBP Mission Statement
To provide excellent service and administrative services to eligible municipalities in Texas by
utilizing innovative, affordable alternatives while maintaining financial integrity.
Not-for-Profit
Member Equity
Operational
Efficiency
Exclusive to Public Sector
Questions?
“May I be excused? My brain is full.”
Thank You!