Item 4BITEM 4B
M E M O R A N D U M
July 30, 2018
TO: Shana Yelverton, City Manager
FROM: Stacey Black, Director of Human Resources
SUBJECT: Approve a contract renewal with Aetna to provide employee health
insurance benefits for Plan Year October 1, 2018 through September 30,
2019.
Action
Requested: Approve a contract renewal with Aetna to provide employee health
insurance benefits for Plan Year October 1, 2018 to September 30,
2019.
Background
Information: Aetna became the City’s health insurance provider on October 1, 2016
following a competitive bidding process, and in June, the City received
its health insurance renewal from Aetna.
Over the last 12 months, the City has experienced a 56% increase in
medical and prescription claims. In addition, Aetna reported that the
City is currently experiencing 15 large, ongoing claims. As a result,
Aetna’s initial renewal offer proposed a 16.5% rate increase. Following
negotiations, Aetna’s final offer proposes a 9% rate increase with no
plan design changes.
In an effort to contain costs, the renewal proposes adding a fourth plan
option. The new plan option is modeled after the City’s most popular
plan, the EPO plan, but introduces a new narrow network. Employees
who elect this option will only have access to providers and hospitals
within the Texas Health Aetna network.
The City’s experience with Aetna has been favorable and very few
service complaints have been received from employees. After a review
of the claims data and given the favorable experience, Staff
recommends Council approve the proposed renewal.
Financial
Considerations: The City’s estimated annual cost is $3,319,932; the estimated annual
increase is $175,813 across all funds.
Shana Yelverton, City Manager ITEM 4B
July 30, 2018
Page 2
The proposed health insurance plan costs will be included in the
proposed budget for Fiscal Year 2019.
Strategic Link: Performance Management and Service Delivery: attract, develop and
retain a skilled workforce.
Citizen Input/
Board Review: N/A
Legal Review: N/A
Alternatives: Deny contract with Aetna and seek alternative options.
Supporting
Documents: The following supporting documents are attached:
• Aetna Renewal
Staff
Recommendation: Approve a contract with Aetna to provide employee health insurance
benefits for Plan Year October 1, 2018 to September 30, 2019.
Financial Renewal Overview: October 01, 2018 through September 30, 2019
Control Number: 229323
A Texas Health Aetna Renewal
Presented to
City Of Southlake
Our simplified navigation center, personal onboarding and data analytics help ensure that members
receive the proper care they need to reach their health ambitions.
Texas Health Aetna ER Doc app.
a more personalized, connected care experience.
Texas Health Aetna is the brand name used for products and services provided by Texas Health +
Aetna Health Insurance Company and Texas Health + Aetna Health Plan Inc.
Health benefits and health insurance plans are offered and/or underwritten by Texas Health +
Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance Company (Texas Health Aetna).
Texas Health Aetna is an affiliate of Texas Health Resources and of Aetna Life Insurance Company
and its affiliates (Aetna). Aetna provides certain management services to Texas Health Aetna.
Each insurer has sole financial responsibility for its own products.
Aetna and Texas Health Aetna have various programs for compensating producers (agents,
brokers and consultants). If you would like information regarding compensation programs for
which your producer is eligible, payments (if any) which Aetna or Texas Health Aetna have made
to your producer, or other material relationships your producer may have with us, you may
contact your producer or your Aetna or Texas Health Aetna account representative.
texashealthaetna.com
The information contained in this proposal is confidential and should not be shared with anyone
other than your broker or benefit plan consultant.
By working closely with local health systems like Southwestern Health Resources, members get
Convenient to access local hospitals, local physicians and local non‐clinical care network
Members get timely access to appointments with primary care doctors, often with same‐day or next
day availability. After‐hours care and 24/7 virtual visits are also available through the
Care that connects all of your providers for a more personalized holistic view of your needs
help drive down costs and create efficiencies.
experience for you and your employees in the Dallas‐Fort Worth metroplex.
We coordinate both clinical and non‐clinical care on a local level to help get members healthy ‐
and help keep them healthy. And we are aligned under one objective: helping members
achieve their health ambitions. By combining our capabilities and bringing down administrative
barriers, we can help ensure you and your employees have seamless access to care.
As a member of Texas Health Aetna, you and your employees can enjoy:
A simple and seamless experience designed to support your health ambitions
Affordability and efficiency
We've negotiated improved pricing for many providers across the Dallas‐Fort Worth metroplex to
Texas Health Resources and Aetna, coming together to fundamentally transform the health care
At Texas Health Aetna we believe that great health starts with great local care that is personalized,
connected and affordable. Texas Health Aetna represents two leading health care organizations,
ober 2017 Page 2
Catherine Walsh
MMA Sr Account Manager
2777 Stemmons Freeway
Dallas, TX 75207
Phone: 214‐200‐8550
WalshC1@aetna.com
City Of Southlake
Stacey Black
1400 Main St, Ste 260
Southlake, TX 76092
To Whom It May Concern:
Thank you for allowing us to serve your health insurance and health benefit needs during the past year.
This package provides information to help you develop the future benefits program for City Of Southlake.
As we approach the anniversary of our relationship in the journey to better health, we are pleased to
present you with this renewal for your 2018 policy period.
It's important to understand the full financial picture of your benefit plan.
■ Future Program Costs
This section illustrates the cost projections to operate your current benefit program for the
period 10/1/2018 through 9/30/2019.
■ Fully Insured Medical Plans
This renewal reflects both the premium and the producer service fee.
■ Caveats
Our renewal offer is contingent upon the parameters outlined here. It is important to note that
deviations from these assumptions may result in additional charges and/or adjustments on our
Medical quotations. Please review this section thoroughly.
If there are no changes that impact the conditions of this renewal as outlined in our Caveats
section, the rates will remain in effect through September 30, 2019.
Sincerely,
Cathy Walsh Julie Tam
Catherine Walsh Julie Tam
MMA Sr Account Manager LG Sr UW Consultant
Each insurer has sole financial responsibility for its own products.
Health benefits and health insurance plans contain limitations and exclusions.
If you'd like to make any plan changes or if you have any questions, please contact me by September 01, 2018 at 214‐200‐
8550. It's been a pleasure working with you and I look forward to our continued relationship.
June 19, 2018
Therefore, the enclosed package provides the following important information about the cost of your current program and
the value we bring to you and your company.
For the period 10/1/2018 through 9/30/2019 the cost to operate your current medical plans will increase 9.0%
compared to the current rate.
06/19/2018 Renewal Letter
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Prospective_Rates
Network Services
−
−
You’ll see consistency in the coordination of care for transplants with our National Medical Excellence
Program®. This case management program provides our members with:
• Access to care through our nationwide network of participating health care providers and hospitals
Accessed November 10, 2017.
National Medical Excellence Program®Cost
Included
regulations.
Citation: 1 Teladoc® 2017. Only Teladoc delivers these episode‐of‐care savings. Available at
https://www.teladoc.com/businesses/health‐plans/
We will continue to encourage using Teladoc®. It’s convenient for your employees to talk with a physician
during their lunch break and then pick up their prescription after work. At only $40 per consultation,
Teladoc has an average savings of $472 per episode of care.1 Video consults not available in all states due to state
And with the recent addition of behavioral health, dermatology and caregiver services to Teladoc, your
employees have even more time‐saving options available to them.
after work. At only $40 per consultation, Teladoc™ has an average savings of $472 per episode of care.1
Video consults not available in all states due to state regulations.
when visiting a doctor in person is not necessary. Teladoc helps prevent unnecessary visits to the emergency
room and urgent care clinics.
Using Teladoc, members can talk with a doctor during their lunch break and then pick up their prescription
Teladoc®Cost
Teladoc®offers 24/7 access to a national network of physicians. They can diagnose, treat and prescribe Included
medication for many common, non‐emergency medical issues via phone or online video at a lower cost
non‐emergent issues any time, from anywhere. The Texas Health Aetna ER Doc app allows members
to connect via secure instant message or to schedule a video visit. The best news is there is no cost
to the member for the visit.
by Texas Health Aetna.
With Texas Health Aetna ER Doc, Texas Health Aetna members can now chat with a local ER Doc about
Transitions, LLP (“ACT”) to provide access to emergency medicine physicians in Texas through the app.
CirrusMD, ACT and the physicians made available through the Texas Health Aetna ER Doc app are independent
contractors and are neither agents nor employees of Texas Health Aetna, its affiliates or plans administered
The Texas Health Aetna ER Doc is a healthcare communications platform that provides access to consultations Included
for non‐emergency issues via instant secure messaging or scheduled video conference. The app was developed
and is serviced by a vendor, CirrusMD Inc. (“CirrusMD”). Texas Health Aetna has contracted with Acute Care
similar benefits when members receive out‐of‐network services involuntarily (e.g., emergencies). The claim
experience for your quoted products also includes NAP access fees (a percentage of NAP savings achieved).
Texas Health Aetna ER Doc Cost
These programs not only save money on eligible claims for your plan but also can help your employees see
lower coinsurance and deductible charges. In addition, the contracted rate component of NAP provides
Review of large facility charges that meet certain criteria (including certain in‐network, inpatient
claims) often results in eliminating certain types of charges prior to claim adjudication.
facility claims where the NAP contracted rate is not available.
• Itemized Bill Review (IBR)
• Facility Charge Review (FCR)
Provides a reasonable charge allowance review for most inpatient and outpatient out‐of‐network
NAP Flex Cost
Your plan and your employees can save money with the Facility Charge Review (FCR) and Itemized Bill Included
Review (IBR) Review (IBR) components of Aetna's National Advantage™ Program (NAP).
Program Summary ‐ Description of Services
City Of Southlake
Programs and Services ‐ Fully Insured Funding Effective Date: October 01, 2018
06/19/2018 Programs and Services FI
City Of Southlake
Programs and Services ‐ Fully Insured Funding Effective Date: October 01, 2018
recognized for successful clinical outcomes
• Specialized case management by nurses experienced with transplants and complex care
• Allowances for transportation and lodging for the patient and one companion may be available if
preapproved by National Medical Excellence and the transplant care is received in an Institutes of
Excellence™ (IOE) facility more than 100 miles from home
• Coordination of follow‐up care
Care Management
MedQuery® Member Messaging
An optional program of MedQuery that includes sending a consumer version of the care consideration by letter to
the member. This letter encourages the member to call his or her doctor to discuss the care consideration and is
sent only after the care consideration is communicated to the treating physician, to allow the physician time to
evaluate the issue.
Regional Case Management
Manage or prevent major health events with early intervention. Through Aetna’s integrated systems and
processes, we can find at‐risk members quickly using:
• Predictive modeling
• Claims data to find high‐cost members
• Utilization management reviews
• Referrals from doctors and Aetna programs
Our Case Management program:
• Improves transition and coordination between multiple providers and varying levels of care
• Reduces unnecessary medical costs and helps members get the care they need
• Maximizes effective use of plan benefits
• Educates members about tools and resources they can use to make health care
• Improves member understanding and management of their health care needs
Cost
Included
devices interventional pain management and hip and knee replacement procedures in all HMO markets and most
of our PPO markets. Our program aims to manage costs through prospective medical review and to encourage
network utilization.
Aetna’s Enhanced Clinical Review program helps contain rapidly rising costs while enabling members to Included
access care using evidence‐based guidelines. Our outpatient precertification process includes high‐tech
radiology procedures, diagnostic cardiology, facility‐based sleep studies and cardiac rhythm implant
Enhanced Clinical Review Cost
Obstetrically trained nurses run our maternity program which aims to improve outcomes, reduce neonatal
services and costs and lower the high cost of care associated with complications.
babies at risk, one individual at a time. After a member completes a pregnancy risk survey by phone or through
our secure member website, she enrolls in the program and participates until after her baby is born. We provide
a personalized, supportive experience for all expectant mothers.
Beginning Right® Maternity Management Cost
Our Beginning Right® maternity program identifies pregnant members with conditions that put them and their Included
the CareEngine applies over 9,000 clinical rule sets that unite a broad range of conditions to a single, combined
patient medical record. These include medical claims, pharmacy, lab results, and self‐reported data.
Cost
Included
you and your employees.
MedQuery is powered by our patented CareEngine® technology. To find opportunities to improve patient care,
guidelines.
The program addresses over 35 chronic conditions and uses the MedQuery safety program to generate
recommendations for care (care considerations). It helps improve health outcomes and in turn lowers costs for
chronic conditions achieve healthy outcomes through advanced tools, techniques and systems. We personalize
the condition coaching for our members to motivate and empower them to change their behaviors and therefore
reduce health risks. We offer member education based on condition‐specific assessments of clinical practice
Aetna Health ConnectionsSM Disease Management Cost
Our Aetna Health ConnectionsSM Disease Management program helps your employees and their families with Included
06/19/2018 Programs and Services FI
City Of Southlake
Programs and Services ‐ Fully Insured Funding Effective Date: October 01, 2018
• Identifies behavioral health concerns that may impact a member’s ability to achieve their health goals
Member Resources
• Access ID card information
Our Servicing Framework puts the member first in every decision and promotes a culture of individual
accountability, trust, ownership and empowerment. Benefits include: Issues resolved faster, the first time. Our
Customer Service Representatives (CSRs) use lifelines that give them real‐time access to support areas.
Technology ‐ CSRs will educate and guide members on the benefits of Aetna's digital tools and programs.
Making it right ‐ CSRs are empowered to make claim decisions in certain situations, while giving them guidance
on how to make the best use of their plan benefits.
Pharmacy Programs
Please note that this is optional on the Premier Plus formulary. We can also offer you our Aetna Rx Step
program that gives you the ability to customize your benefits approach. You’re able to elect all of the 13
that our system will allow a claim for a specific drug to be processed, without intervention, if a member’s
claim history indicates that the predefined criteria have already been met.
Through our step therapy program, members must try one or more therapeutically equivalent prerequisite Included
drugs before a step therapy drug will be covered. One of the benefits of Aetna’s step therapy program is
Step Therapy Cost
Your members get your best coverage when they use generics. When a drug has a generic equivalent, but a brand drug Included
is filled, members will pay the difference in cost between the generic and brand drug in addition to the required copay
or coinsurance. We strongly encourage plan sponsors to implement Choose Generics for considerable savings.
Choose Generics Cost
• View coverage and benefits
• Email member services
Enhanced Customer Servicing Framework Cost
Included
• Find a doctor, dentist, hospital or urgent care facility
• View a map of the office location and call the office with the tap of a finger
• Estimate costs of care
• Manage prescriptions
• Search claims
• View health history
• Participate in online wellness programs
• Find a doctor
Our free app provides on‐the‐go capabilities and lets members and their families care for their health easily and
simply, from anywhere. We even offer fingerprint login capabilities. With the Aetna Mobile app, members can:
• Access personal health benefits
• Review claims status and details
• Compare provider costs and read reviews
• View health history
• Access wellness discounts
• Take health assessment
Web and Mobile Experience Cost
Members have 24 hour access to our web and mobile experience, including our secure website and mobile app. Included
Our simple to use, intuitive, on‐the‐go member website, is an online resource for personalized health and
financial information where members can:
24/7 Nurse Line ‐ Informed Health® Line Cost
24‐hour nurse 1‐800 supportline ‐ Members can call anytime and talk to a registered nurse for answers to health Included
related questions. They can also listed to information from our audio health library on thousands of topics.
24/7 Call Service Cost
Members can speak with a Member Services representative 24 hours a day, 7 days a week. The service is Included
available every day except select holidays.
06/19/2018 Programs and Services FI
City Of Southlake
Programs and Services ‐ Fully Insured Funding Effective Date: October 01, 2018
Reporting
Behavioral Health
AbleTo programs. Each program includes eight weeks of personal professional support through web‐based video
conferencing or by telephone.
The AbleTo program makes it easy for our members to get the behavioral health help they need — before it can Included
complicate the health conditions they are already dealing with. We identify members with specific conditions or
life events that could benefit from behavioral health support. Members are then invited to join one of the
(there is a minimum monthly charge of $150).
Able To Network ‐ subject to member cost share Cost
COBRA Services COST
Our rates exclude COBRA direct billing. If this service is elected, additional charges will be billed as Not
incurred. Please contact your account executive or account manager for a detailed Cobra proposal. Included
•3,000 ‐ 4,999 10
•100 ‐ 2,999 5
•20,000+ 50
•5,000 ‐ 19,999 25
Medical subscriber volume number of hours per annum
Information AdvantageTM.
Prepaid hours are available for customized reporting as follows:
We produce standardized reports based on Underwriting’s release policy for full‐risk, experienced‐rated
customers They are available through your account representative on a bi‐annual basis of 100‐199
covered employees and on a monthly bases for at least 200 covered employees through Aetna Health
refine how they look at the data with options such as time period, products, age, gender, region, clinical,
geographic and provider specific detail.
comparisons.
Each module can be drilled down into more detailed reporting and graphs allow users to group and
high‐cost claimants, network savings and membership. These topics, called modules, are produced at the
customer level by funding arrangement and product type on an incurred basis with a two‐month claim lag.
The modules offer a high‐level view of the current data as well as book of business and prior year
plan decisions more quickly and confidently using focused, experience‐driven data.
Interactive data analysis can be performed on topics such as key measures, components of medical trend,
Utilization Management Reporting Cost
Aetna Health Information AdvantageTM (AHIA) gets you the important plan performance information you Included
need, when you need it. It’s a rapid and flexible decision support tool that helps you make benefits and
key drug classes, or just choose the classes you want.
06/19/2018 Programs and Services FI
Aetna Healthy Commitments℠ ‐ Core Program and Tools Effective Date: October 01, 2018
Wellness Programs Included to Help Members Stay Healthy and Improve Productivity
• Adaptive Technology
• Gaming Mechanics
• Proven behavior science methodology
Advocacy & Outreach Programs
24/7 Nurse Line ‐ Informed Health® Line
While only your doctor can diagnose, prescribe or give medical advice, the Informed Health Line nurses can provide
information on more than 5,000 health topics. Contact your doctor first with any questions or concerns regarding your health
care needs. Informed Health Line nurses do not diagnose, prescribe or give members medical advice.
exclusions and limitations.
Members can save on gym memberships, weight loss programs, eyeglasses, LASIK laser eye surgery, massage therapy and
much more!
This material is for information only. Health information programs provide general health information and are not a substitute
for diagnosis or treatment by a physician or other health care professional. Health benefits and health insurance plans contain
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by location and are subject to change. Discount programs
provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted
services. Information is believed to be accurate as of the production date; however, it is subject to change.
Aetna Discount Programs
Our discount program helps members save money on a wide variety of products and services for themselves and their family.
Provides members easy access to face‐to‐face lifestyle and preventive coaching support in their neighborhood CVS
MinuteClinics.
Communications Campaigns and Toolkits
Member Wellness Message Program
Electronic communications for employees that address general health and wellness topics, available in English and Spanish.
Neighborhood Well‐being Services
Online Wellness Programs
Our online health coaching programs called Journeys®, make engagement simple, and use choice architecture – a powerful
technique derived from behavioral economics. Participants choose a Direction and then answer a few questions to help
personalize their Journey experience. Your subscribers will embark on a Journey that is tailored to their unique needs and
preferences. Journeys are developed to maximize engagement and positive outcomes through use of:
Available programs include: Be Tobacco Free, Blood Pressure in Check, Diabetes Life, Eat Healthier, Get Active, Healthy Back,
Heart Healthy Cholesterol, Living Well with Asthma, Sleep Well, Stress Less, Weigh Less, and Health In A Hurry.
Our Informed Health® Line provides members with telephone and e‐mail access to experienced registered nurses to help them
make informed health care decisions. Nurses are available through a toll‐free telephone number 24 hours a day, 7 days a week.
Simple Steps To A Healthier Life® ‐ Our online, personalized health and wellness program that includes a health assessment and
online health coaching programs. Based on information gathered in the health assessment, the participant receives a
personalized HealthMap, containing online coaching program recommendations to help them achieve and maintain good
health.
Incentives
Plan sponsors can add an option whereby subscribers and their spouses can each earn a $50 gift card after completing both
the Health Assessment and a minimum of one Online Health Coaching Program Journey.
Subscribers and their spouses can each earn a $50 gift card after completing both the Health Assessment and a minimum of
one Online Health Coaching Program Journey.
Health Assessment (Supported by Incentives)
Simple Steps To A Healthier Life®
City Of Southlake
January 2018 Page 12
exclusions and limitations.
change.
For information about Aetna plans, refer to:
GR‐29/GR‐29N.
Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company
This material is for information only. Health information programs provide general health information and are not a substitute
for diagnosis or treatment by a physician or other health care professional. Health benefits and health insurance plans contain
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and
conditions of coverage. Plan features and availability may vary by location and are subject to exclusions, limitations and
conditions of coverage. Plan features and availability may vary by location and are subject to change.
Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full
cost of the discounted services. Information is believed to be accurate as of the production date; however, it is subject to
www.aetna.com
Policy forms issued in OK include: HMO/OK COC‐5 09/07, HMO/OK GA‐3 11/01, HMO OK POS RIDER 08/07, GR‐23 and/or
Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health of California
For information about Aetna plans, refer to:www.aetna.com
January 2018 Page 13
City Of Southlake
Caveats ‐ Fully Insured Funding Effective Date: October 01, 2018
Assumptions
Prospective Quoting
The quoted insured medical rates are offered on a prospectively rated basis. No policy year accounting balance will be
calculated for these coverages.
Billing and Payment of Premium
Amount due is payable on the first day of the month covered by the invoice. If the amount due is not paid in full within 30
days, we reserve the right to terminate the contract and/or assess late premium payment charges.
Claim Fiduciary
Aetna will be the ERISA claim fiduciary for medical coverages. As claim fiduciary, Aetna
will be responsible for final claim determination and the legal defense of disputed benefit payments for medical
Commissions
Commissions have been excluded from our quoted rates.
Producer Service Fee
•The quote includes a Producer Service Fee of 4.2% of the Total Amount Due as determined between the Plan
Sponsor and Producer and memorialized in the Billing and Collection Agreement.
•The Producer Service Fee is negotiated directly between Plan Sponsor and Producer for services provided in
connection with the Group Medical benefit plan. Producer Service Fee is not a component of the premium but is
included in the Total Amount Due.
•The Producer Service Fee will be removed from the Total Amount Due if a Plan Sponsor and Producer do not
agree on a service fee amount and sign a Billing and Collection Agreement.
•The Plan Sponsor is not required to use a Producer to purchase insurance and may purchase a policy directly
from our company.
•The Plan Sponsor selects, retains, and contracts with the Producer on its own accord.
•The Plan Sponsor voluntarily chooses to pass the fee or commission through the issuer and is not required to do
so by our company. The Plan Sponsor may also elect to pay the fees or commissions directly to the Producer.
Contract Period
Our policies provide for automatic renewal upon the completion of each contract period unless either party invokes the
termination provision requiring 31 days advance written notice of termination to the other party. This provision may be in‐
voked at any time during the continuance of the contract (that is, not just limited to termination occurring on the renewal date).
Contributions
We standardly require that the employer contribute 75% of the employee cost, or 50% of the total employee
and dependent cost. Employer contributions may not favor other medical plans over that of the Aetna plans. Our
plan will have neutral to favorable employer contributions after adjusting for plan design, compared to other medical
plans, including consumer directed plans (HRA and/or H.S.A. models). In option situations, employer contributions
must not disadvantage our offering.
Eligibility
Eligibility applies to:
• Permanent full‐time employees working 25 hours or more per week, on a regularly scheduled basis.
• Eligible dependents include an employee’s spouse, domestic partner, and children up to the limiting age of the
plan or as mandated by legislative requirement.
• Individuals cannot be covered as an employee and dependent under the same plan.
• Children eligible for coverage through both parents cannot be covered by both under the same plan
Financial Condition
Plan Sponsor is a legitimate business and meets underwriting approval for acceptable financial strength. We reserve the
right to request additional supporting information in order to evaluate financial status.
Mandates
Benefit provisions are subject to state, local, and federal mandates. Future mandates will be incorporated in the plan(s) as of
the date required by law and may require rate adjustments.
Plan Design
Network Re‐Contracting
In addition to standard fee‐for‐services rates, contracted rates with network providers may also be based on case and/or
per diem rates and in some circumstances, include risk‐adjustment calculations, quality incentives, pay‐for‐performance and
other incentive and adjustment mechanisms. These mechanisms may include payments to organizations that may refer to
themselves as accountable care organizations (“ACOs”) and patient‐centered medical homes (“PCMHs”), in the form of
This renewal is based on the current benefit plan designs, plus any noted deviations. Our standard provisions, contract wording and claim
settlement practices will apply for items not specifically outlined.
06/19/2018 Caveats FI
accountable care payments (ACP) and incentive arrangements based on clinical performance and cost‐effectiveness. The
ACP amount is based upon an assessment for each member who is already accessing providers in an ACO, and is
assessed retrospectively on a quarterly basis and collected through established claim wire. Each ACO will have a different
ACP based on the clinical efficiencies targeted and network negotiations. The ACP assists the ACO in funding transformation
of the health care system to improve quality, reduce costs and enhance the patient experience by:
• Identifying and engaging patients at risk for health crises sooner through more data‐sharing
• Increasing patient engagement in best‐in‐class care management programs through doctor‐driven outreach
• Delivering better health outcomes through increased collaboration between the health plan and ACO providers
We reserve the right to revise the premium, modify the terms of the offer, or terminate if:
Member/Subscriber Ratio
The enrolled member to subscriber ratio increases or decreases by more than 10% from the 2.16 ratio assumed in this quote.
Enrollment
The actual enrollment in total or by plan changes by more than 10% compared with what was proposed.
The plan sponsor offers coverage to employee previously not covered under the plan without prior notification
(Change in census is based on additions and subtractions ‐ a 60 life group who adds 3 people and takes away 3 others has a 6
person change in census even though they stay at 60 lives.)
Participation and Contribution Rules
Under Affordable Care Act (ACA) and state insurance regulations, a group health insurance policy may be non‐renewed for
certain reasons. We reserve the right to non‐renew for failure to comply with certain requirements such as participation
and/or contribuƟon rules.
Contract Provisions
The final benefit provisions, account structure, claim payment requirements or services change from those proposed.
Covered Lives, Demographics
A 5.0% percent change in the demographics and/or geographic mix of the enrolled group in aggregate or in any site with at
least 100 enrolled subscribers. A 10 percent change in the total number of subscribers enrolled in each individual product
or in aggregate, including the impact of new or terminating locations and/or groups.
Quoted Benefits
A material change in the plan of benefits offered, or a change in claim payment requirements or procedures, or a change in
state premium taxes or assessments, or any other changes affecting the manner or cost of providing coverage that is
required because of legislative or regulatory action.
Additional
Medical EOBs
We make EOBs available through our secure Navigator website for subscribers who have registered to use Navigator and
for whom we have a valid email address. We send members an email when a new EOB is available. All other members
receive paper EOBs. If a member receiving EOBs electronically prefers paper EOBs, they can get them by telling us that is
their preference. Please note that unless required by state law we do not produce EOBs for claims when there is no
member liability.
Medical Disclosure Information
At the time of annual enrollment, your plan participants should be provided with the Medical Disclosure information related to
their plan of benefits. Go to our corporate website and enter the state followed by the word 'Disclosure' in the search field
Please provide the applicable Medical Disclosure document and any required Addendum to your plan participants. If you have
any questions, please contact your broker or account management team.
Health Care Reform Caveats
Healthcare Reform Disclosure
This renewal is intended to be compliant with health care reform.
Under the federal health care reform legislation, health plans existing prior to the enactment of the Affordable Care Act may
be "grandfathered" and not subject to some of the mandated benefits and reform provisions. Changes in your benefit design
as well as your contribution strategy may affect grandfathering. Plan sponsors are required to notify us if their contribution
rate changes for a grandfathered plan at any point during the plan year.
This renewal offer assumes your plan is not grandfathered.
As a non‐grandfathered plan, the plan will include Preventive care as defined by regulation without cost sharing on In Net‐
work services.
06/19/2018 Caveats FI
Certain employers and organizations may be exempt from contraceptive services coverage requirements, and
choose an optional accommodation. If you qualify and want to be exempt from including ACA contraceptive services
benefits in your policy, please work with your Account Manager/Account Executive to provide the required documentation to
us so that we can administer accordingly. We have the right to treat insured plans as subject to the ACA contraceptive
services coverage requirements without an executed certification document. Applicable state laws requiring coverage of or
related to contraceptive services benefits still may apply.
Except for specific and limited scenarios described as transitional rules in the health care reform legislation, if a plan's grand‐
fathered status has been lost, it cannot be regained. If, after reviewing the grandfathering rules with your benefit consultant
or counsel, your determine that your coverage could be or is grandfathered, and you want to retain grandfathered status,
please contact us for further instructions.
We reserve the right to treat an insured plan as non‐grandfathered.
Retiree Only Plan Status Certification
Guidance issued by the Internal Revenue Service (“IRS”), Department of Labor (“DOL”), and Department of Health and
Human Services (“HHS”) has indicated that “retiree only” plans are exempt from the benefit mandates under ACA including
Medical Loss Ratio (“MLR”) and rebate requirements for insured plans (Retiree only plans are subject to certain ACA fees
and assessments). In order to demonstrate the establishment of a retiree only plan, a plan should maintain, separately from
the plan for current (i.e., active) employees, a separate plan document and Summary Plan Description (SPD) and file a
separate Form 5500. If you have a retiree only plan, and want to be considered exempt, please provide the required
documentation to us. We have the right to treat insured plans as subject to ACA without an executed certification document.
Waiting Period Requirement
When renewing your plan(s) with us, you represent that:
• You will give us effective dates for your employees and their dependents that take into account all state and
federal eligibility conditions and waiting period requirements, including a reasonable and bona fide orientation
period.
• If this information changes, you will inform us immediately.
Summaries of Benefits and Coverage (SBC)
The SBC must include statements about whether the plan or coverage provides minimum essential coverage (MEC)
and if the coverage meets minimum value (MV) requirements.
Under the Affordable Care Act (ACA), minimum value and minimum essential coverage determinations are associated with
the employer shared responsibility provisions. We will review the minimum value standard for each plan based on the MV
calculator criteria provided by the Department of Health and Human Services (HHS) and will indicate within the SBC whether
the plan meets or does not meet the MV standard based on this review. We do not provide legal or tax advice, and
recommend that plan sponsors consult with their own legal and tax counselors when reviewing MEC and MV
determinations. We have no responsibility or liability regarding the minimum value or minimum essential coverage
evaluation, regardless of the role we may have played in reviewing/producing the SBC documents. To the extent you disagree
with our evaluation, we will make changes to reflect your determination, as you are responsible for the final determination of
these SBC elements.
Employer Reporting Requirements
Under Internal Revenue Code (IRC) Section 6055 health insurance issuers, certain employers, government agencies and
other entities that provide Minimum Essential Coverage (MEC) to individuals must report to the IRS information about the type
and period of coverage and furnish related statements to covered individuals. This information is used by the IRS to
administer the individual shared responsibility provision and by individuals to show compliance with the individual shared
responsibility provision.
For insured group health plans, the reporting obligation under Section 6055 is our responsibility. We will report the required
information to the IRS about the type and period of coverage provided to each individual member enrolled in our insured
plans, and will furnish the required statements to subscribers.
We must report the entire Social Security numbers (SSN) to the IRS for each sub‐
scriber and dependent in order to complete our required reporting. However, the final rules allow the use of truncated socia
security numbers on statements furnished to individuals (for example, give only the last four digits of the SSN). If we don’t
receive the SSN through the employer, the law requires we reach out to each subscriber up to three separate times to
request the information.
IRC Section 6056 requires applicable large employers (those having employed an average of 50 or more full‐time employees
during the preceding calendar year) to report to the IRS information about the health care coverage they have offered and
also furnish applicable statements to employees. The purpose is to allow the IRS to enforce the employer responsibility
provisions.
This renewal includes the women's preventive care coverage requirements, e.g., coverage for contraceptive methods and counseling, breastfeeding
support and equipment, and prenatal care.
06/19/2018 Caveats FI
To satisfy the 6056 employer reporting requirements, an applicable large employer must file the required returns with the IRS
by no later than February 28 of the year following coverage (if filing on paper) or March 31 (if filing electronically), and
furnish a statement to all full‐time employees by January 31st of the year following the calendar year to which the return
relates.
06/19/2018 Caveats FI
The Federal Mental Health Parity and Addiction Equity Act Effective Date: October 01, 2018
The Federal Mental Health Parity and Addiction Equity Act (MHPAEA) requires parity in coverage for mental health and substance abuse services compared
to medical and surgical services. The law allows outpatient benefits to be sub‐classified between "office visits” and "all other" outpatient services.
Beginning on 1/1/18, or your next renewal date, we are changing your benefits separating Outpatient Mental health/Substance Abuse into two new benefi
categories: BH Office Visit and BH All Other.
• "BH Office Visit " includes services where members will interact with a provider in an office setting for treatment
• "BH All other" includes services where members will have some other interaction with providers in obtaining care – such as technological intervention o
where the service is traditionally delivered outside an office setting, like in the home
Beginning January 1, 2018, the following Behavioral Health services will be classified as behavioral health outpatient “all other” for purposes of Federa
Mental Health Parity law:
• Partial hospitalization programs (PHP)
• Intensive outpatient programs (IOP)
• Applied behavior analysis (ABA) for the treatment of autism spectrum disorder
• Home health care
• Transcranial magnetic stimulation
• Electroconvulsive therapy (ECT)
• Vagus nerve stimulation (normally an excluded benefit)
• Outpatient monitoring of injectable therapy
• Psychological testing
• Neuropsychological testing
• Medical treatment for withdrawal symptoms
• Outpatient detoxification
• Ambulatory detoxification
•2 3‐hour observation
In an effort to comply with the new law, we are also revising several medical, mental health and substance use disorde
benefits cost share. In order for your plan to pass the ‘substantially all” and “predominate” cost share testing required by MHPAEA, the following medica
benefits cost share may change with your renewal:
• Lab
•X‐ray noncomplex and X‐ray complex
• Outpatient Surgery Freestanding
• Outpatient Surgery Hospital
• Medical Injection in an Office Visit
• Home Health
• Outpatient Hospice
In addition, the behavioral Health All Other benefit will have a cost share that is equal to or better than the above medical benefits
City Of Southlake
06/19/2018 Federal Mental Health Parity