ACA
This is a skinny medical plan that satisfies a requirement and avoids the larger penalty for employers to offer coverage.
Minimal Essential Coverage (MEC)
It's how long you should reasonably give a carrier to provide a medical quote.
2-3 Weeks.
These are the two main reports that any self-funded group can get on a monthly basis.
Aggregate report and 50% report.
Although they are one in the same, one usually is tied to a bundled self-funded carrier that is commercial while the other is tied to an unbundled administrator.
Administrative Services Only(ASO) and Third Party Administrator(TPA)
It's indemnification coverage for employers to limit their financial liability on each member individually
Specific Stop Loss
To be an Applicable Large Employer (ALE), what must you have?
50 FTEs in a given year.
These are the main fully-insured carriers in Ohio.
Aetna, Anthem, Cigna, MMO, UHC
This is the size of fully-insured group that gets comprehensive claims data.
100+ enrolled
This disease creates special medicare primary rules.
End Stage Renal Disease (ESRD)
This is a stop loss contract that has gaps and does not cover a "full" 12 months of claims.
Immature Contract. There is generally a 15-20% load for a mature contract. The most common example of an immature contract is a 12/12
This a form that covers the medical benefits and is required to be given to each member at least once a year.
Summary of Benefits and Coverage.
A company has 30 FT employees and 25 PT EEs, what medical size segment should they be shopped in?
Large group. Despite the number of FT or FTEs, if the group has more than 50 total employees, the carriers will push them to large group.
If an employer that is self-funded with Anthem has 3 people that go over the specific deductible and they equal $40,000 over in that month. How much stop loss reimbursements will they be granted in that same month?
$40,000. With a commercial carrier, there is no lag between reimbursements. It is simultaneous.
Name three of our biggest competitors in our market.
Mcgohan Brabender, USI, Oswald, Hylant, OPOC, and Preferred.
This is the main law that governs self-funded health plans.
Employment Retirement Income Security Act (ERISA). In SF plans, federal law superceeds state law and state specific laws are rarely applicable to SF'd plans.
The ACA made all fully insured products for individuals and small groups with 2-50, and in some states 2-99, have these kind of rates?
Adjusted Community Rates - not based on risk and is age banded by each age year (30,31,32, etcc..)
It's an exclusive product with Anthem that has a wellness program embedded in it.
ERC Health
How many months of claims for the current plan year will a stop loss carrier want in order to "Firm" up?
10 Months (60 day lock). Some will do 90 day lock, very few will do 120 day lock. The longer the group has been with that carrier, the longer out the carrier will lock in.
This is where an employer cuts ties with a standard PPO network and negotiates directly with a provider.
Reference Based Pricing
John Smith's Spec deductible is $300,000 when the remaining employees have a deductible of $50,000. What is this an example of?
A laser. In the occasion of a laser, the employer is responsible for paying all of that individual's claims until they reach their specific laser amount - past the other EE deductibles.
This is the only remaining fee/tax from the ACA that is imposed on employers.
PCORI Fee.
An HR manager calls and says their employee can't login into their FormFire account because they can't get past the Google page. What do you do?
Bypass the second-step google authenticator in the individual's settings.
This is the monthly limit that a group would have to pay in total claims prior to any aggregate stop loss reimbursements.
The monthly attachment point.
This is an arrangement where self-funded employers band together to stabilize their healthcare costs and fund and additional layer of protection together.
Captive Stop Loss
What are the two most common forms of self-funding a group of 10 would do?
Level-Funding and HRA.