UFCW LOCAL 1000 & KROGER DALLAS
HEALTH AND WELFARE PLAN
December 15, 2015
Presentation to UFCW Local 1000 Shop Stewards
AGENDA
I. Introduction
II. Administrative Manager’s Presentation
III. Consultant’s Presentation
IV.Cigna Presentation
V. MedExpert Presentation
ADMINISTRATIVE MANAGER’S
PRESENTATION
WHO IS NEBA?
NEBA stands for “National Employee Benefits Administrators, Inc.”.
NEBA is a Third Party Administrator (TPA) that specializes in administering benefit plans
that cover employees working under Collective Bargaining Agreements (CBAs) with
various Unions across the United States.
NEBA has been in business for over twenty (20) years and employs approximately
eighty (80) union members covered under a Collective Bargaining Agreement with the
United Food and Commercial Workers Local Union 1625.
WHAT DOES NEBA DO FOR THE MED-1000 PLAN?
 NEBA…
 Collects contributions from Kroger & Participants
 Determines who is eligible for benefits and which plan they may
qualify for
 Sends eligibility information to other parties that provide benefits,
such as:
 Dental Insurance Provider
 Vision Insurance Provider
 Life Insurance Provider
 Provider Network and Medical Management Program Provider
 Kroger - Pharmacy Program Provider
 MedExpert – Employee Assistance with Individual Medical Decisions Program Provider
 Administers COBRA when Participants lose coverage
WHAT DOES NEBA DO FOR THE MED-1000 PLAN? (continued)
NEBA…
 Processes self insured claims
 Medical claims
 Life insurance claims
 Short Term Disability / “Loss of Time” claims
 Provides Member Services to Participants
 Provides general Administration Services to the Trustees
 Accounting
 Compliance
 Etc.
ELIGIBILITY: HOW IS IT DETERMINED?
Employees may qualify
for the Med-1000 plans
based on:
• length of
employment;
• number of hours
worked; and
• status as either Full
Time or Variable Hour
employees.
Hire Date
Hours Worked
Employee Status
ELIGIBILITY: HOW IS IT DETERMINED?
•
Kroger submits a monthly report of hours
worked by each employee in the
bargaining unit
•
The report includes hire dates and other
information that is used to determine
eligibility
•
NEBA credits each employee with their
hours worked
•
NEBA applies the Med-1000 Plan’s
eligibility rules to determine who is eligible
WHEN DOES ELIGIBILITY BEGIN?
WORK, ADMINISTRATIVE LAG AND COVERAGE PERIODS
Work, Administrative Lag and Coverage Periods
Fixed “Standard” Measurement Periods for earning initial or continuing coverage for all Plans other than Plan C
Standard Measurement Period in Which
Administrative Lag Period
Coverage Period
Minimum Hours are Accumulated
May - October
November - December
January - June
November – April
May - June
July - December
Work, Administrative Lag and Coverage Periods
Each Calendar Month is a Measurement Period for earning initial or continuing coverage for Plan C
Measurement Period in Which Minimum Hours
are Accumulated
Administrative Lag Period
Coverage Period
January
February-March
April
February
March-April
May
Etc…
WHAT PLANS ARE AVAILABLE TO VARIABLE HOUR
EMPLOYEES?
Plan C – Employee Only
4th Month
Plan E – Employee/Child
9th Month
Plan D-Family
13th Month
Plan B-Employee Only
25th Month
Plan A - Family
25th Month
•60 Hours per Month
•780 Hours in 6 Months
• 720 Hours in 6 Months or
• 1,200 Hours in 12 Months
•192 Hours in 6 Months
•720 Hours in 6 Months
WHAT PLANS ARE AVAILABLE TO FULL TIME
EMPLOYEES?
Plan E – Employee/Child
1st Month After 60 Days
Plan D - Family
13th Month
Plan A - Family
25th Month
•No Minimum Hours
Required
• 720 Hours in 6 Months or
• 1,200 Hours in 12 months
•720 Hours in 6 Months
WHAT BENEFITS ARE AVAILABLE UNDER EACH PLAN?
Major Benefit Provisions as of 1/1/2016
Coinsurance
PCP &
Specialist
Copay
70%
$25
70%
$25
75%
$25
Plan
Deductible
Out of
Pocket Max
C
$400
$4,000
E
$400 Individual
$1,200 Family
D
$400 Individual
$1,200 Family
B
$400 Individual
$4,000
Individual
75%
A
$400 Individual
$1,200 Family
$2,500
Individual
$5,000 Family
80%
$4,000
Individual
$8,000 Family
$4,000
Individual
$8,000 Family
Vision &
Dental
Benefits
Dependent Coverage
Spouse
Child
N
N
N
Y
Dental &
Vision
Y
Y
$15
Dental &
Vision
N
N
$15
Dental &
Vision
Y
Y
Vision
13th Month
Vision
13th Month
HOW DO PARTICIPANTS ENROLL?
• New Hires are sent enrollment
instructions upon hire and again
when they first qualify for
coverage
• Open Enrollment is held annually
during the last quarter of the
year
• Special Enrollment is available if
Participants have a life event
• The enrollment website is
www.mybenefitplaninfo.com
Cycle
of a
Claim
HOW DO CLAIMS GET PAID?
Healthcare Provider
Visit
NEBA Issues
Explanation of
Benefits to
Participant
Healthcare Provider
Submits Claim to
Cigna
NEBA Issues
Payment or Denial
to Provider
Cigna Reprices Claim
and Submits to
NEBA
NEBA Processes the
Claim
CYCLE OF A CLAIM: HEALTHCARE PROVIDER VISIT
• Patient Visits Healthcare Provider
• Patient Presents their Cigna ID Card
• Healthcare Provider Calls NEBA to
Verify Eligibility and Benefits
• NEBA Provides Eligibility Verification
• NEBA Provides a Summary of Benefits
Available
• Patient Receives Healthcare Services
CYCLE OF A CLAIM:
HEALTHCARE CLAIM SUBMISSION & REPRICING
• Healthcare Provider Submits a Claim
to Cigna Which Includes Details
Regarding the Healthcare Services
Provided
• Cigna Reviews the Claim and Applies a
Discount Based on the Agreement
They Have with the Healthcare
Provider
• Cigna Discounts in 2015 Have Been in
Excess of 50%
CYCLE OF A CLAIM:
HEALTHCARE CLAIM ADJUDICATION
• Cigna Submits “Repriced” Claim Reflecting
Discounts to NEBA for Adjudication
• NEBA Reviews the Claim and Determines if the
Claim is Payable
•
•
Is the Patient Eligible?
Are the Services Covered?
• NEBA Applies the Med-1000 Benefits, such as
Copays, Deductibles, etc.
• NEBA Calculates the Amount Due to the
Provider or Participant
EXPLANATION OF BENEFITS:
WHAT DOES IT MEAN?
• The Explanation of Benefits (EOB) Provides Details Regarding
how a Claim was Adjudicated
• The EOB shows if the claim was approved or denied.
•
If the claim was denied, the EOB shows the reason and refers the
Participant to the correct pages in the Summary Plan Description to
learn more about the reason for the denial
• The EOB shows the amount applied towards the Patient’s
Deductible
• The EOB shows the amount of copay the healthcare provider
should have collected during the patient’s visit
• The EOB tells the patient and the healthcare provider how much
the patient owes
• The EOB tells the healthcare provider how much the Patient’s bill
should be discounted
• The Patient should always confirm that the healthcare provider is
billing them correctly by comparing the bill to their EOB
EXPLANATION OF BENEFITS:
WHAT DOES IT MEAN?
• The Explanation of Benefits (EOB) Provides Details Regarding
how a Claim was Adjudicated
• The EOB shows if the claim was approved or denied.
•
If the claim was denied, the EOB shows the reason and refers the
Participant to the correct pages in the Summary Plan Description to
learn more about the reason for the denial
• The EOB shows the amount applied towards the Patient’s
Deductible
• The EOB shows the amount of copay the healthcare provider
should have collected during the patient’s visit
• The EOB tells the patient and the healthcare provider how much
the patient owes
• The EOB tells the healthcare provider how much the Patient’s bill
should be discounted
• The Patient should always confirm that the healthcare provider is
billing them correctly by comparing the bill to their EOB
EXPLANATION OF BENEFITS:
WHAT DOES IT MEAN?
• The Explanation of Benefits (EOB) Provides Details Regarding
how a Claim was Adjudicated
• The EOB shows if the claim was approved or denied.
•
If the claim was denied, the EOB shows the reason and refers the
Participant to the correct pages in the Summary Plan Description to
learn more about the reason for the denial
• The EOB shows the amount applied towards the Patient’s
Deductible
• The EOB shows the amount of copay the healthcare provider
should have collected during the patient’s visit
• The EOB tells the patient and the healthcare provider how much
the patient owes
• The EOB tells the healthcare provider how much the Patient’s bill
should be discounted
• The Patient should always confirm that the healthcare provider is
billing them correctly by comparing the bill to their EOB
EXPLANATION OF BENEFITS:
WHAT DOES IT MEAN?
• The Explanation of Benefits (EOB) Provides Details Regarding
how a Claim was Adjudicated
• The EOB shows if the claim was approved or denied.
•
If the claim was denied, the EOB shows the reason and refers the
Participant to the correct pages in the Summary Plan Description to
learn more about the reason for the denial
• The EOB shows the amount applied towards the Patient’s
Deductible
• The EOB shows the amount of copay the healthcare provider
should have collected during the patient’s visit
• The EOB tells the patient and the healthcare provider how much
the patient owes
• The EOB tells the healthcare provider how much the Patient’s bill
should be discounted
• The Patient should always confirm that the healthcare provider is
billing them correctly by comparing the bill to their EOB
EXPLANATION OF BENEFITS:
WHAT DOES IT MEAN?
• The Explanation of Benefits (EOB) Provides Details Regarding
how a Claim was Adjudicated
• The EOB shows if the claim was approved or denied.
•
If the claim was denied, the EOB shows the reason and refers the
Participant to the correct pages in the Summary Plan Description to
learn more about the reason for the denial
• The EOB shows the amount applied towards the Patient’s
Deductible
• The EOB shows the amount of copay the healthcare provider
should have collected during the patient’s visit
• The EOB tells the patient and the healthcare provider how much
the patient owes
• The EOB tells the healthcare provider how much the Patient’s bill
should be discounted
• The Patient should always confirm that the healthcare provider is
billing them correctly by comparing the bill to their EOB
EXPLANATION OF BENEFITS:
WHAT DOES IT MEAN?
• The Explanation of Benefits (EOB) Provides Details Regarding
how a Claim was Adjudicated
• The EOB shows if the claim was approved or denied.
•
If the claim was denied, the EOB shows the reason and refers the
Participant to the correct pages in the Summary Plan Description to
learn more about the reason for the denial
• The EOB shows the amount applied towards the Patient’s
Deductible
• The EOB shows the amount of copay the healthcare provider
should have collected during the patient’s visit
• The EOB tells the patient and the healthcare provider how much
the patient owes
• The EOB tells the healthcare provider how much the Patient’s bill
should be discounted
• The Patient should always confirm that the healthcare provider is
billing them correctly by comparing the bill to their EOB
FUND CONSULTANT’S
PRESENTATION
Jim Crump
UFCW LOCAL 1000
The new Patient Protection and Affordable Care
Act (ACA) contains provisions that impact health
plans such as MED 1000 and UFCW Local 1000
Oklahoma Health and Welfare Plan.
24
ACA PLAN PROVISIONS
• No Lifetime or Annual Limits
2010 Annual Maximum
Plan A
Plan B
Plan C
Plan D
$100,000
$ 30,000
$ 20,000
$ 50,000
2014 Annual Maximum
Unlimited
Unlimited
Unlimited
Unlimited
25
ACA PLAN PROVISIONS (continued)
• Minimum Essential Coverage
•
•
•
•
•
•
•
•
•
•
Ambulatory patient services,
Emergency Services,
Hospitalization,
Maternity and newborn care,
Mental health and substance use,
Prescription drugs – Kroger Plan
Rehabilitative services,
Laboratory services,
Preventive and wellness service and chronic disease management,
Pediatric services, including oral and vision care.
26
ACA PLAN PROVISIONS (continued)
• Coverage of Adult Children Up to Age 26.
• Emergency services without prior authorization and covered at InNetwork rates. (non-grandfathered plans).
• Plans may not impose a waiting period of more than 90 days.
• Plans may not impose pre-existing condition exclusions on any
participants.
• Plans do not have to offer coverage for Spouses.
27
INCREASED BENEFIT COST
MED 1000 Medical Claims Per Employee Per Year (All Plans) – Does not
include Dental, Vision, Disability, Administration, PPO fees, or Stop Loss
Insurance.
2010
$3,059
2011
$3,577
2012
$4,489
2013
$4,906
2014
$5,480
2015
$6,664
Medical Claim Cost has more than doubled since ACA was enacted!
28
MED 1000 FINANCIAL SUMMARY
12 Months Ending September 30, 2015
Additions
Kroger Contributions
Employee Contributions
Investment Income
Deductions
Benefits Paid
Other Benefit Expenses
Administrative Expenses
Change in Fund Equity
$31.8 million
$ 2.3 million
$ .9 million
$35.0 million
$38.7 million
$ 2.7 million
$ 2.0 million
$43.4 million
($8.4 million)
29
NEW TAXES, FEES and STOP LOSS PREMIUMS
ACA has imposed fees, taxes and premiums that did not previously exist.
Reinsurance Fee
Payable by Self-Insured Plans to subsidize the Individual Health Insurance market.
2014
$63 per covered life
2015
$44 per covered life
2016
$27 per covered life
Patient-Centered Outcomes Research Institute Fee (PCORI Fee)
2014
$2 per covered life
2015
$2.08 per covered life
2016
$TBD
MED 1000 paid or will pay more than $466,000 in 2014 and $365,000 in 2015 for
the Reinsurance and PCORI Fees.
30
NEW TAXES, FEES and STOP LOSS PREMIUMS
(continued)
Health Insurer Fee
Payable by Health Insurance Companies, based on market share and
intended to generate substantial revenue to help pay for ACA. This fee
is passed on to consumers in the form of higher premiums.
Cadillac Plan Tax
•
Effective 2018
•
40% of the value above $10,200
31
NEW TAXES, FEES and STOP LOSS PREMIUMS
(continued)
Stop Loss Premiums
Self-insured plans like MED 1000 and CARE 1000 purchase Stop Loss
Insurance to cover large claims. Because Annual Limits are not
permitted, the cost of Stop Loss Insurance has increased significantly.
Claims in excess of $1 million are now occurring regularly.
MED 1000 will pay more than $700,000 in 2016 for Stop Loss
Insurance.
32
MANDATES AND PENALTIES
Individual Mandate and Penalty
Penalties to Employees for Not Maintaining ‘Minimum Essential
Coverage’ with either Medicare, Medicaid, Individual Insurance
Policies, Employer or Taft-Hartley Sponsored Plans.
2014
$95 per adult and $47.50 per child
2015
$325 per adult and $162.50 per child
2016
$695 per adult and $347.50 per child
33
MANDATES AND PENALTIES
(continued)
Employer Mandate
Employers with 50+ full-time employees must offer medical coverage
that is “affordable” and provides “minimum value” or else be subject to
Employer Penalties (below).
Coverage is “affordable” if employee contributions are less than 9.5%
of Employees W-2 wages.
A plan must pay 60% of the cost of covered health services to be
considered “minimum value.”
34
MANDATES AND PENALTIES
(continued)
Employer Penalties
If employer does not provide “affordable” “minimum value” coverage
the penalty will be the lesser of:
•
$2,000 for each employee, minus the first 30; or
•
$3,000 for each employee who receives a subsidy for coverage
on an exchange.
35
CIGNA
WELLBEING
PARTNERSHIP
UFCW “Med 1000” Kroger Dallas Stewards
December 15th, 2015
Jodi Berry
Dawn Godard
Thank You! – We appreciate the opportunity to work together with
everyone here today, to support providing educational communications
to the members!
Drive Member Engagement
• Provide the packet today, with copies of the key member
communications . Custom one page member flyer.
• Educate on Emergency Room alternatives. Provide a member letter
or e-mail sample and UC/CC In-Network directories for the Dallas, TX
area.
• Provide helpful focus topics quarterly, in PDF’s to post to local
websites and provide newsletter content.
• Provide step by step instructional on online provider look-up guide.
Promote PCP and Cigna Designated Specialty provider selection.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2015 Cigna
37
Goals and Objectives
Objectives
Goal 1
Increase health
awareness
• We want to ask for your partnership to Drive member awareness in Cigna toll free
support lines, online website wellness tools and programs and to help members and
their dependents be empowered to make better health decisions.
• Partner today, with the Trustees, Stewards and NEBA, to coordinate quarterly periodic
member communications, on key topics and provide healthy recipes and nutritional
and fitness tips. Please help us promote this member engagement!
Goal 2
Increase health and
wellness events
onsite
• Promote the members to get their Preventive Care screenings with biometrics and
knowing personal health numbers to address any identified risk.
• Increase group.MyCareallies.com personal website user awareness, utilization
and taking the Health Assessment.
• Educate membership to call the Cigna 24 hour health information nurse line for
decision support on health decisions and steerage in choosing a Participating
Provider
• MedExpert vendor also available, for additional medical inquiry information
Goal 3
Implement a robust
communication
campaign to create
awareness of…
• Partner to help educate the members on alternatives to the ER. Encourage members
to choose participating UC/CC when appropriate, for cost savings and a better quality
of care.
• Key focus on Maternity Health. Provide support and education on having a healthy
pregnancy, to support healthy babies
• Increase member awareness in Cigna Care Allies Case Managers. Encourage
members to Take the call and Make the call, to utilize the Case Management.
Goal 4
Improve plan
utilization
• Educate and create awareness on the Healthy Rewards member discounts and
cost savings program on health care items for fitness, weight management and
quitting tobacco. Support healthy pregnancies and help address chronic conditions.
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2015 Cigna
38
Introduction to MedExpert
December 15, 2015
(c) 2015 MedExpert International, Inc. | Confidential
Independent
Experienced
Vetted
CA-based
30+ years to build
CMS Health Care Innovations Award
No Compromising Affiliations
10+ years with UFCW Funds
5 year longitudinal study with
Harvard, Stanford, and MIT
On-staff physicians and nurses
Over 125,000 UFCW lives covered
(c) 2015 MedExpert International, Inc. | Confidential
40
Mission Statement
MedExpert’s mission is to improve lives of UFCW members through the timely
exchange, understanding, and implementation of current, unbiased, and accurate
medical and health information. MedExpert believes that every UFCW member,
regardless of language, education, or station in life, deserves today’s finest medical
knowledge delivered in a prompt, honest, clear, and respectful manner.
This mission is possible through a robust knowledge system that identifies EBM quality
information within 4 to 8 minutes and exchanges that knowledge through MedExpert’s
knowledge transfer platform.
(c) 2015 MedExpert International, Inc. | Confidential
41
MICOMM™
Advanced Telecomm System
UFCW Members will always
be automatically routed to
their MedExpert case
manager.
<0.025
Seconds
<1.00
<1.00
Second
Second
<2.00
Seconds
MICOMM™ Features:







Fully integrated with knowledge (FAME ™) and EHR system (MILS™)
Phone number identified in <0.025 seconds
Call routed to Member’s Personal Case Manager in < 1.00 seconds
EHR loads with member information in <2.00 seconds
No phone trees
No voice mail
Current engineered capacity 3,000,000 calls every 4 hours
(c) 2015 MedExpert International, Inc. | Confidential
42
TM
MedExpert QMMS Products & Services
MedExpert
QMMS™ Products &
Services
MISP1
MISP2
MISP3
MISP4
MISP5
MISP6
MISP7
(Quality Medical Management
System)
MISP8
MISP9
MISP10
MISP11
MISP12
MISP13
MISP14
MISP15
MISP16
MISP17
MISP18
MISP19
MISP20
MISP21
MISP22
MISP23
MISP24
MISP25
MISP26
Medical Decision Support
IMDS ™ (Individual Medical Decision Systems)
Biometric
Body Composition | BMI | Waist | BPF
Glucose | Fasting Glucose | A1c
Lipid | Cholesterol | HDL/LDL | Triglyceride
Blood Pressure
Assessment Execution
Health Risk | HRQ | LLL
Health Plan | CAHPS
Provider | VSQ9
Disease Risk | Asthma + >75 assessments
Screening & Toxicology
Nicotine | Cotinine
FIT
Schedule C Drugs
Utilization | Case Management
Informed ™ (Prospective Utilization/Case Management)
Independent Utilization Review
Medical Management
Health Coaching
Chronic Disease Management
Directly Observed Therapy (DOT)
Wellness
Smoking Cessation
Nutrition Fundamentals™
Exercise On!
Sleep Soundly
Stress Less
Data Management
MICore™
MI Data Analytics
QMMS™ Incentive Management
Member Program Agreement Fulfillment
(c) 2015 MedExpert International, Inc. | Confidential
IMDS™ (Individual Medical Decision Systems) is
based on artificial intelligence that required over
a decade to develop.
IMDS™
 covers all 22,000+ conditions;
 16,000+ pharmaceuticals;
 all wellness issues and
 300,000+ co-morbidities.
43
Co-Branding to
Provide Numerous
Modes of
Engagement
(c) 2015 MedExpert International, Inc. | Confidential
44
(c) 2015 MedExpert International, Inc. | Confidential
45