April2013Cover2013 PPO Survey–PPO Power – Our Annual PPO Survey – Part II
Welcome to Part II of our 13th annual PPO survey. For this survey, seven PPOs in California diligently answered direct questions about their plans. Our readers, who are savvy health brokers, suggested many of the questions.
We hope this information will help the professional agent or broker better serve sophisticated healthcare clients.
Why Self Funding Should Be Available to Small Employers 
by Mark Reynolds, RHU • Let’s hope that, for the benefit of citizens in California who covered by their employer’s plan, that our legislature sees the wisdom in retaining self-funded plans for small employers.
Navigating Clients Through Health Reform in 2014
by David Zanze •  Although there are many benefits to remaining self-funded in the current environment, your clients will need to consider certain regulations before deciding whether to offer health benefits to their employees.
Health Reform Changes – What’s Coming and What’s Already Here
by Sean O’Connor • Certain provisions of the Affordable Care Act (ACA) have received more air time than others, such as the individual mandate and health insurance exchanges. There are many more important changes to be aware of — some of which are already in effect. Let’s take a closer look at how ACA will affect Americans.
Chiropractic/Acupuncture – The Hidden Benefits of Chiropractic and Acupuncture 
by George W. Vieth, Jr. and Joel Stevans, D.C., PhD
In a benefit landscape of high cost trends, ever increasing premiums, and skinnier benefits, offering chiropractic and acupuncture coverage to your groups is an opportunity to offset this tide.
Long-Term Care – When the Need for LTC Coverage Hits Home
by Maxwell Schmitz  • Give your clients the opportunity to explore LTC insurance before they are caught in the safety net.
Disability – Making a Difference With Disability Management Programs – A Case Study
by Alison Daily • By offering a versatile disability management program, brokers can help clients strengthen their benefit offerings to attract and retain top talent, boost employee morale and, most importantly, maintain productivity during still uncertain times.
Life Lines – Are the Singles Market and Life Insurance Technologies the Keys to More Life Sales?
Life Insurance – A Life-Changing Decision for Single Parents
by John T. Harmeling • While life insurance is an important part of financial planning for everyone, it’s especially important for single parents.
To Sell Life Insurance Technology,  Sell the Benefits
by John West •  Brokers who sell life insurance products have turned administrative stresses into sales successes by providing clients with life insurance products that are equipped with electronic technology.

PPO Power – Welcome to Part II of Our 13th Annual PPO Survey

Welcome to Part II of our 13th annual PPO survey. For this survey, seven PPOs in California diligently answered direct questions about their plans. Our readers, who are savvy health brokers, suggested many of the questions.
We hope this information will help the professional agent or broker better serve sophisticated healthcare clients.Look for Part II in our April issue. We will be posting the survey on our Website at www.calbrokermag.com.

8.Which Requested Procedures are Denied Most Frequently on the Basis of “Experimental/Investigative” or “Not Medically Necessary” Exclusions?
Aetna: We seek to minimize the number of claims denied based on medical necessity through our extensive patient management program, which includes features such as pre-certification, concurrent review, and close communication among our staff and attending physicians.
Blue Cross: It varies greatly. Each request is reviewed on a case-by case basis to determine medical necessity based on the latest medical standards. Factors that might influence the decision would be the season, say during flu season, or the age of the member for a certain procedure.
Blue Shield: Each request is reviewed on an individual basis to determine medical necessity. We do not have statistics on which procedures are most frequently denied.
Cigna: CIigna has a comprehensive policy for ensuring the efficacy of the latest medical treatments. We have an extensive process that includes review of outside, professional literature and input from physicians to determine the safety and efficacy of procedures and interventions. We work closely with customers and physicians to help determine treatment protocols that ensure appropriate and quality care while reducing the number of denials.
Health Net: N/A.
Kaiser Permanente: Requests are received on a case-by-case basis.
UnitedHealthcare: UnitedHealthcare does not deny procedures on the basis of medical necessity and our benefit plans do not contain medical necessity exclusions. We believe that healthcare consumers and their doctors are best qualified to make decisions about healthcare. Denials on the basis of “experimental or investigative” are very rare. If an individual has a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), we may determine that an experimental, investigational, or unproven service meets the definition of a covered health service for the sickness or condition. This determination is based on whether we find the procedure or treatment to be promising and that we find that the service uses research protocol that meets standards equivalent to those defined by the National Institutes of Health.

9.Do You Capitate PPO Providers? If Not, How Are They Compensated?
Aetna: No. Physicians are paid based on a negotiated fee schedule,  which compensates physicians at the lesser of their usual charge or the negotiated fee. Each of our networks has a unique fee structure. We incorporate the federal government’s RBRVS methodology for procedure-related services while allowing for local differences for office and hospital visit services.
Blue Cross: No, payment is determined by applying available member benefits to a pre-determined fee schedule.
Blue Shield: Blue Shield does not capitate PPO providers. PPO contracted providers (physicians and ancillary providers) have agreed to accept Blue Shield’s allowances as payment in full, which are valued-based and reviewed annually.
Cigna: No, we reimburse physicians on a maximum allowable fee schedule or a discounted fee-for-service arrangement. For physicians who are part of our collaborative accountable care initiatives, we also provide reimbursement for care coordination services and have a pay for performance component if physicians meet  targets for improving quality and lowering medical costs.
Health Net: PPO physicians are typically reimbursed at a discounted contract-fee schedule
Kaiser Permanente: No, our PPO providers are part of the Private Healthcare Systems (PHCS) Network. PHCS Network contracts with the Providers to negotiate a lower rate for services rendered. Providers are paid based on claims submitted for covered services.
UnitedHealthcare: The majority of physicians in our networks are reimbursed according to a Maximum Allowable Fee Schedule based on the Resource Based Relative Value Scale Fee Schedule (RBRVS). Our fee schedule is established by applying a conversion factor to RBRVS values. The conversion factor is based on competitive market conditions, medical expense expectations, and physician acceptance. The advantage of this funding arrangement is that we reimburse physicians only for services rendered based on time and intensity with adjustments for geographical differences. For some high-cost specialists, we employ prepayment (capitation). This ensures that we are able to manage expenses for high-cost services to a planned target.

10. What Happens When a Member Provider Bills a Participant Inappropriately for Services?
Aetna: Balance billing of the patient is not permitted. The provider-relations staff monitors compliance and educates providers. A provider who is found to have inappropriate balance billing may have his or her contract terminated in some cases.
Blue Cross: Customer service works with the member and provider to resolve billing issues. Dispute-resolution procedures are available to members and providers.
Blue Shield: Network providers are prohibited from balance billing patients. When a member is billed inappropriately for services, Blue Shield customer service representatives can usually resolve the issue by contacting the provider’s office to clarify the member’s benefit and the Blue Shield reimbursement schedule.
Cigna:  Our contracts prohibit balance billing by physicians. The customer  should contact us about the issue and we will investigate. Our customer service associates are available by phone 24 hours a day, seven days a week.
Health Net: Health Net will intervene on the member’s behalf by working directly with the provider’s office.
Kaiser Permanente: In the unfortunate event that a provider bills an insured inappropriately, the insured should contact the KPIC customer service line at 1-800-788-0710. If the issue requires any type of special handling, KPIC operations staff will intervene and assist in reconciling the claim.
UnitedHealthcare: Our physician and other healthcare professional contracts preclude physicians and other healthcare professionals from balance billing enrollees. The contracts also address how physicians and other healthcare professionals must submit claims. We take appropriate action if network physicians or other healthcare professionals attempt to balance bill enrollees or to bill enrollees for covered services in breach of their contract requirements. We protect our customers from claims liability by fulfilling all state mandates concerning participation in guaranty associations, maintaining state contingency reserve requirements or obtaining reinsurance agreements. Our standard hospital contracts also contain provisions to protect individuals receiving health services from balance billing when an insurer becomes insolvent. If a network physician or other healthcare professional becomes insolvent or otherwise unable to continue to render healthcare services to individuals, we help reassign individuals enrolled in our plans to other physicians.

11. Do You Have a Registered Nurse on Call 24 Hours a Day for Questions at the Plan Level and the PPO Level?
Aetna: Yes, nurses provide information on a broad spectrum of health issues virtually 24 hours a day, seven days a week. They also provide ongoing follow-up information as needed and perform customized research when appropriate. Standard service is included in the full-risk, prospectively rated PPO plan. The informed Health Line may be purchased as an additional service for self-funded or retrospectively rated PPO plans with over 1,000 or more total enrolled employees. The minimum group size can be a mix of active employees and retirees (e.g., 800 active and 200 retirees).
Blue Cross: Yes, most PPO members have access to professional, reliable healthcare information toll-free, 24 hours a day, seven days a week. Registered nurses answer questions and help with decisions. Members also have access to educational audiotapes on more than 200 health topics.
Blue Shield: Yes, Blue Shield’s NurseHelp 24/7 is a service for all of our fully insured groups and is available as a buy-up for self-insured groups. It provides a nurseline, which is staffed 24 hours a day, seven days a week with registered nurses and master’s-level counselors. Any member of a fully insured Blue Shield health plan can take advantage of this service at no extra charge.
Cigna: Yes, Cigna’s customer service line is open 24/7 365 days a year. We also offer a 24-hour Health Information Line staffed by nurses.
Health Net: Yes, Nurse24 is a nurse-driven telephonic support program that empowers participants to better manage their health. Nurse24 SM offers assistance to participants coping with chronic and acute illness, episodic or injury-related events and other health care issues. Highly trained registered nurses are available 24/7 to monitor and process health care inquiries that help participants make informed health care decisions. The Nurse24 SM program is accredited by both URAC and NCQA.  Access to evidence-based, reliable clinical support for decision support after hours increases the likelihood that our members will seek care at the appropriate level when their physician is not available to support the decision.  Seeking care at the appropriate level increases the efficiency and reduces the cost of after-hours care. Program highlights include:
• Chat capability from our website with Nurse24 SM clinicians
• Health information managers with experience in health issue discovery and trained in telephone triage
• Improved continuity of care – integration with Decision Power disease management services
• Significant cost savings potentia – convenient and useful alternative help to reduce excessive or unnecessary emergency room visits
• Access to nationally recognized  Healthwise(r) Knowledgebase with more than 5,500 health topics
Kaiser Permanente: The insured have access to Kaiser Permanente Healthy Solutions, which will give them access to a personal health coach, online health and wellness programs and information, and the Kaiser Permanente Healthwise Handbook online. (Services under the Healthy Solutions program are value-added services provided by Kaiser Permanente Healthy Solutions, an affiliate of Kaiser Foundation Health Plan Inc. (KFHP). These services are not in lieu of any services covered under the PPO Group Policy. Likewise utilization of these services does not constitute receipt of benefits under the PPO Group Policy. The Kaiser Permanente PPO Plan is underwritten by Kaiser.)
UnitedHealthcare: Optum, the UnitedHealth Group care management company, provides toll-free, 24-hour, 365-day access to the “NurseLine.” Experienced registered nurses discuss treatment options and help individuals get the appropriate level of care. NurseLine gives individuals information that helps them make educated decisions about their personal health and use of medical resources. Some services must be purchased as a buy-up based on the funding arrangement of the plan.

12. What is the Plan or PPO Doing to Have Online Systems for Eligibility, Administrative Changes, Referrals, Etc.?
Aetna: EZLink streamlines several benefits and HR functions. It links to our enrollment and billing systems and provides real-time eligibility; online enrollment, account maintenance, online billing, and electronic-funds transfer for payment.
Blue Cross: Our Website offers online services to providers and members for eligibility, claim status, and benefit inquiries. Other features include a provider finder and a wide variety of Web and organizational resources.
Blue Shield: Our website has a password-protected section with personalized member health plan account information. Members can view detailed benefit information and find customer service phone numbers and addresses. Via e-mail, they can reach customer service, submit changes to account information, request new member ID cards, download claim forms, and request a new personal physician. Blue Shield can offer online enrollment to all our employer groups through our partnership with leading online vendors. This partnership gives benefit administrators direct access to the eligibility system as set up by the vendor allowing for functions such as employee eligibility tracking, plan enrollment, open enrollment, and life event enrollment transactions. Additionally, the use of an outside vendor allows for incorporation of benefit design from more than one carrier, providing employer groups with a single online enrollment service.
Cigna: The Cigna for Health Care Professionals website (www.cignaforhcp.com) offers secure and easy access to real-time transactions such as pre-certification, claim status, eligibility, and benefits. Information on Cigna policies and procedures is also available. In addition, Cigna has enhanced the myCigna.com portal, which enables members to personalize their site for their individual use. Information includes the ability to review hospital and provider quality data, gather specific disease information, track claims and explore drug alternatives that might be a cost savings.
Health Net: Health Net’s website, www.healthnet.com, is a secure website that requires a personalized identification number (PIN). Members, employers, providers and brokers can perform a wide range of online administrative functions. Members in an active or COBRA program can view or modify their enrollment information. Providers can verify eligibility, find specialists for referrals, and submit and check claims status. Health Net’s  Online Billing and Enrollment for members, brokers, and employers offers 24-hour online account access to process enrollment and maintain member’s eligibility; users can also view, print and pay billing. Enhancements for both sites are ongoing.
Kaiser Permanente: Kaiser Permanente offers online billing and administration functions to its employer groups through a system called Online Account Services-www.kp.org/accountservicestour.
UnitedHealthcare: Members, physician, and employers have access to their data and the capability to communicate directly with us online. Our consumer Internet solution – myuhc.com – allows people to do the following:
• Choose a plan.
• Locate network professionals.
• Access claims history and explanations of benefits (EOBs).
•Complete a health assessment and develop an action plan.
•Order ID cards and print temporary ones.
•Communicate with a nurse.
• Compare hospitals.
Healthcare professionals can do the following:
•Verify patient eligibility, applicable co-payment amounts, and YTD and out-of-pocket accumulators.
•Search the notification database and complete multiple notifications in one session
•Submit claims.
•Receive payment statements and reimbursement.
•Perform online reconciliation and electronic funds transfer.
•Submit credentialing data online.

Complete online CE programs
The following features are available through Employer eServices:
•Receive Web-based eligibility management.
•Get simplified invoices, real-time calculations, and downloadable data.
•Do Customer reporting
•Get Claim status information.

13.What is the Relationship of your HMO Provider Network (if you have one) to Your PPO Provider Network? Do HMO Providers Have to Participate in the PPO Network? How big is your PPO Network compared to your HMO Network?
Aetna: Standard provider contract provisions generally apply to all of our plans and products that the provider participates in. However, it is not mandatory for a provider to participate in all products.
Blue Cross: All of our California networks are proprietary, whether they are PPO/HMO/EPO etc. A provider may participate in one or more of our plan products, but it is not mandatory for a provider to participate in all products. Our physician network has more than 57,000 members.
Blue Shield: Blue Shield’s HMO and PPO networks are separate. The HMO network is capitated based on medical group and IPA contracts throughout the state with some directly contracted networks in specific geographies.
With the PPO, there are value-based allowances and contracts with individual physicians and medical groups. HMO providers do not have to participate in our PPO network, though many of them do.
Blue Shield’s PPO network has 65,000 physicians (defined by access points) and 350 hospitals, and our HMO network has 32,000 physicians (defined by access points) and 300 hospitals.
Cigna: Cigna does not require PPO network physicians to participate in the HMO (or vice versa). The HMO network is contracted with Cigna HealthCare of California Inc. The PPO network is contracted with Connecticut General Life Insurance Company, a Cigna company. While there is considerable overlap, we have many physicians just in one network (e.g. PPO only). In California, our HMO network is about 80% of the size of our PPO Network.
Health Net: Health Net of California has taken a multi-product approach in contracting with providers, with approximately 65% of Health Net’s PPO network practitioners also participating in the HMO network. While HMO providers are not required to participate in Health Net’s PPO network, approximately 88% of them do so. Health Net of California’s HMO network includes more than 49,000 Primary Care Physicians and specialists in the California 30-county HMO service area and more than 65,500 Primary Care Physicians and specialists in the PPO network.
Kaiser Permanente: Our PPO and HMO networks are not affiliated. For our PPO, KPIC contracts with PHCS Network to provide access to providers and facilities nationwide. They currently have more than 658,000 providers and 4,200 acute care facilities nationally and more than 68,000 providers in California. Our HMO offers more than 9,100 providers and more than 160 facilities in California.
UnitedHealthcare: UnitedHealthcare’s network includes 570,000 physicians and healthcare professionals and 4,800 hospitals nationwide. In general, UnitedHealthcare’s contracts apply to all of our commercial products ensuring that employees have a consistent experience throughout the country. Providers are not required to participate in all our products, but the majority of them do. The UnitedHealthcare Select or Choice HMO networks apply locally and are subject to state laws.

Self Funding – Prohibiting Self Funding For Small Employers Would Drive up the Uninsured Rate

by Mark Reynolds, RHU
Will the Affordable Care Act (ACA) actually increase the number of uninsured? The answer may lie in legislative attempts to eliminate self-funding for small employers — employers that are simply trying to provide a group health plan for their employees. If current legislative efforts are successful in restricting access to reasonable self-funding alternatives, there is a real probability that we will see higher uninsured numbers in California in 2014.

First Let’s Frame The Discussion
To outline the issue, we must consider a few facts and statistics. Let’s estimate for this discussion that California’s population is 35 million. Based on recent presentations by Covered California, experts estimate that 5.3 million California citizens are uninsured.
Covered California recently provided these statistics about the 5.3 million uninsured:
•2.7 million will probably qualify for the ACA tax credits available through our Exchange.
•2.6 million will not qualify for subsidies in 2014.
To frame the discussion, let’s add a few other statistics:
•More than 95% of California’s employers have fewer than 50 employees.
•Roughly 50% of those small employers provide no benefits to employees.
•The primary reason for not providing benefits is cost.
•Small employers will not have a penalty if they do not provide health insurance.
•Premiums for individual and family plans (IFPs) and group plans are projected to increase dramatically in 2014.

One starts to see a picture that stimulates the following questions:
Question: If 2.6 million people, who will not qualify for subsidies, don’t buy insurance now why would we expect them to buy in 2014 when premiums are higher?
Answer: It is probable that none of this group gets insured unless their employers offer coverage.
Question: How many of the 2.7 million people who qualify for a subsidy will actually be able to afford the coverage even with the subsidy?
Answer: It is projected that many of these people will be unable to afford the coverage.
Question: If 50% of small employers don’t provide coverage now, what would compel them to provide insurance in 2014?
Answer: There is very little hope that these employers will start to offer coverage in 2014.
Question: Will increased premiums in 2014 affect an employer’s decision to stop providing benefits?
Answer: Increased cost may drive tens of thousands of employers to terminate their current plans.
Question: If small employers that are providing benefits now decide to stop providing benefits, how many of those newly uninsured people will buy coverage on their own?
Answer: This newly uninsured group will be much like the current uninsured population. They will make their buying decision based on affordability and their own health care needs.
Question: How important is it to make sure that the 50% of small employers who provide benefits now continue to provide benefits in 2014?
Answer: It is critical if we hope to increase the number of people insured in CA.
The last question is the basis of this article. Our political leaders in California should have great concern about the uninsured population increasing in 2014. If small employers have the alternative of self-insuring their medical plans impeded in any manner, it will increase the probability that the number of small employers not providing benefits will increase.
Pending Legislation May Impede Small Employers

Last year, it was SB 1431; this year, it is SB 161, also known as the “stop-loss bill.” This bill is written with guidelines to place limits on stop loss policies purchased by small employers. The restrictions and limits within the current status of the bill would effectively eliminate self-funded plans as an alternative for small employers.

Last year, there was enough written about SB 1431 to stir up the activist in us all. This year little has been written, but many groups are working vigorously, behind the scenes, to mitigate the damage that would be caused by SB 161. Once again, CAHU’s lobbyist group, CA Advocates, is deeply involved with the ongoing negotiations. Just as last year, CA Advocates is joined by other industry and business groups to confront the misunderstandings about self-funding as well as educate the proponents about the positives of self-funding for small employers. But, as usual, the fight is an uphill battle.

However, this article is not really about SB 161. It is about the reality that our legislators face that the number of uninsured in California may increase from the current estimates of 5.3 million to as high as 6-7 million in 2014. It is really in the math; for thousands of small employers the math may not add up.

Everybody Loves A Number, So Let’s Look At A Few

As stated above, let’s assume that California has 35 million people and 5.3 million are uninsured. That leaves roughly 30 million people currently covered. Let’s also assume that the roughly 50% of small employers that provide benefits cover about 10 million people. That leaves 20 million that are covered by large employers, Medicare, Medi-Cal, Tricare, IFPs, Calpers, etc.

So that poses some questions:

1. How many of these 10 million members will lose their employer sponsored plans because the employer will not be able to afford the increased premiums?
2. How many of these members will not qualify for a subsidy and therefore be unable to afford coverage just like the 2.6 million current uninsured mentioned above?
3. How many of these will qualify for subsidy but will not be able to afford the net cost after the subsidy just as the 2.7 million mentioned above?
4. How many of the newly uninsured will be shopping for their own health insurance for the first time in their life and therefore be shocked by the cost?

The answer to the above is that now is not the time to throw any restrictions on options small employers have to finance their employee’s group health plan.

What Does This Mean To California’s Employers, Employees, And Economy?

Self-funding for small employers is not new in California, but is often misunderstood. Some politicians are honest proponents of the ACA and are truly looking for ways to increase the number of covered citizens. Some politicians are proponents of a single payer system and see the Exchange as a step toward that goal of single payer universal care. Regardless of how one feels about the ACA, it is counter to the benefit of our citizens to limit small employers when employers are trying to provide coverage to their employees.

Employers with fewer than 50 employees are not mandated to provide coverage and bear no penalty if they don’t provide coverage. So why would our leaders want to make it more difficult for small employers to provide coverage if the goal of the legislature is to cover as many Californians as possible? I know, dumb question to ask in the context of politics.


Most of us are not politically active; we are usually too busy just trying to do our job to the best of our ability to get involved with causes. If stop loss bill SB 161 is still alive as you read this article, you will have a chance to make a difference. A phone call to your local state senator or assembly member is a start. If you place a call to the Governor’s office to let him know the potential impact to the uninsured numbers in California it will make an impact. Also, contact your self-funded employer clients and ask them to do the same. They will be impressed that their consultant is involved in shaping the future of financing their health plans.

In May, carriers will be submitting their new plans to Covered California for consideration. Hopefully, soon thereafter, we will see the first indication of what rates and plan designs will be in 2014. Our assumptions and projections will either prove to be true or not.

Let’s hope that, for the benefit of citizens in California who are covered by their employer’s plan, that our legislature sees the wisdom in retaining self-funded plans for small employers. q


Mark Reynolds is a member of the team at BEN-E-LECT. BEN-E-LECT’s trademarked Employer Driven Health Plan(tm) model provides MERPs, HRAs, and self-funded plans to thousands of employers throughout California and the Southwest United States. BEN-E-LECT’s ERISA or E-Based health plans help employers from 2-500 lower and control the cost of their group health plans. BEN-E-LECT’s Employer Driven Health Plan(tm) model has been lowering employer cost since 1996.  BEN-E-LECT’s corporate office is located in Visalia, California. Mark can be reached directly at 559-250-2000 or markr@benelect.com. The Web address is www.benelect.com.

Self Funding – Navigating Clients Through PPACA Requirements in 2014

by David Zanze
With 2014 on the horizon, employers and brokers are gearing up for the continued impact of the Patient Protection and Affordable Care Act (PPACA). Although there are many benefits to remaining self-funded in the current environment, your clients will need to consider certain regulations before deciding whether to offer health benefits to their employees.
The first determination to make before January 1, 2014 is whether your client will be considered an “Applicable large employer.” Applicable large employers must decide whether to face tax penalties or offer a minimum level of coverage to at least 95% of full-time employees and their non-spousal dependants.

How to Calculate Whether Your Client Qualifies As an Applicable large employer

An applicable large employer is one that has had at least 50 full-time or full-time equivalent employees during the previous calendar year. Your client will be considered an applicable large employer in 2014 depending on the hours that both full- and part-time employees worked during 2013.
The proposed regulations state that a full-time employee is one who is employed at least 30 hours per week, on average. As a group, the hours worked by part-time employees are included in the calculation as “full-time equivalents.” In a given month, your client would add all of the hours worked by part-time employees and divide the total by 120. (This calculation would not include more than 120 hours of service for any one employee.)

What About Smaller Employers?

Your client will be considered a small employer if it has fewer than 50 total full-time employees and full-time equivalents. In that case, the tax penalties under PPACA do not apply. In 2014, a Small Business Health Options Program (SHOP) will be available in California to small businesses.

What Are the Penalties?

Beginning January 1, 2014, an applicable large employer would face a tax penalty for not offering a minimum value health plan: $2,000 per full-time employee. (The first 30 employees are excluded from this calculation.)
An applicable large employer would also face a penalty if it offers coverage, but the coverage is deemed unaffordable or inadequate and at least one full-time employee receives a tax credit or subsidy to purchase coverage through the exchange. The penalty would be $3,000 for each employee for each year they receive a subsidy. (Again, the first 30 employees are excluded from this calculation.)
Coverage is considered unaffordable if the employee must contribute more than 9.5% of their household income for their premium. Coverage is considered inadequate if the plan does not cover at least 60% of a person’s medical costs on average.
Potential penalties are applicable on a month-by-month basis. Minimal essential coverage is not yet defined expressly. So it’s key to stay abreast of upcoming regulations for employers to stay in compliance with federal law.

What About Dependent Coverage?

Under the proposed regulations, employers that choose to offer plans must also offer coverage to employees and their qualified dependents. The IRS defines dependents as children up to age 26 including stepchildren, adopted children, and foster children, but excludes spouses.

Should Your Client Offer Benefits or Pay the Penalty?

In some cases, it may be cheaper for your clients to send employees to the exchange and face a tax penalty, but they should weigh the benefits of offering health care coverage to attract and retain qualified talent.

Upcoming Fees For Self-Funded Plans

Your clients will need to be prepared to pay a few upcoming fees if they continue to offer health care coverage next year. Beginning in 2014, all fully insured and self-funded plans must pay an annual transitional reinsurance fee of $63 per covered life. Self-funded plans can choose from various methods to determine the number of covered lives.

Third-party administrators are required to remit the fee on behalf of their clients. Self-funded, self-administered plans with no TPA will pay this fee directly. The Dept. of Health and Human Services (HHS) will collect the reinsurance fees on an annual basis. By November 15 of each year, the employer must disclose the number of covered lives subject to the fee for that calendar year. HHS will generate an invoice and payment will be due within 30 days. Fees are reduced in 2015 and end in 2016.
There is also the Patient Centered Outcomes Research Institute (PCORI) trust fund fee. It will be used to fund comparative clinical effectiveness research. The fee is $1 per covered life for policy years ending between September 30, 2012 and October 1, 2013. The fee is $2 per covered life for policy plan years ending October 1, 2013 through September 30, 2014. The fee must be filed by July 31 of the calendar year immediately following the last day of the plan year. After September 30, 2014, the Secretary of Treasury will adjust the fee based on increases in projected per capita national health expenditures. The PCORI fee will phase out in 2019.

Regardless of how your client decides to offer health care benefits in 2014, there will still be many advantages to remaining self-funded. Remember, self-funded clients have more flexibility in plan design and employee contributions. They are better situated to control their costs via care management solutions and wellness integration. Self-funded clients can also establish network alternatives to help to offset the costs of offering a health benefit plan.

Brokers must be proactive during this critical time for their self-funded clients. Stay informed of the latest developments in legislation and help your clients abide by all the regulations and deadlines to ease this transition. You and your clients have the opportunity to further strengthen your relationship and cultivate new partnerships as everyone journeys into the uncharted territory that is health care reform.
David Zanze has more than 30 years experience serving as a leader and innovator in the health care industry. He joined Pinnacle Claims Management Inc. as president in 1996. Pinnacle Claims Management, Inc. (Pinnacle) is an all-inclusive health benefits third party administrator (TPA) that offers competitive, cost efficient claims management in tandem with the latest technology. Pinnacle administers benefits for a diverse range of small to large sized employer groups from all business sectors of the marketplace. For more information call 866-930-7264 or visit www.pinnacletpa.com.

Health Reform Changes –What’s Coming and What’s Already Here

by Sean O’Connor
Health care reform has not suffered from a lack of media attention. But certain provisions of the Affordable Care Act (ACA) have received more air time than others, such as the individual mandate and health insurance exchanges. There are many more important changes to be aware of — some of which are already in effect. Let’s take a closer look at how ACA will affect Americans.

Rules on Deducting Medical Expenses

The ACA changes how we can deduct medical expenses during tax season. As you may already know, qualified individuals may deduct expenses, paid over the past year, for medical and dental care for themselves, a spouse, or any dependents.

As noted in the Internal Revenue Service Publication 502, Medical and Dental Expenses, “Medical care expenses could include payments for the diagnosis, cure, mitigation, treatment or prevention of disease, or payments for treatments affecting any structure of function of the body.” The list goes on and on, but treatments could include prescription drugs, acupuncture, contraception, eyeglasses, insurance premiums and much more.

Previously, individuals were allowed to deduct medical expenses on their tax returns so long as the costs exceeded 7.5% of their adjusted gross income (AGI). For example, if you made $40,000 and had medical expenses over $3,000 ($40,000 x 7.5%), you could deduct those expenses.
As of January 1, 2013, that threshold increased 2.5% to 10% of your AGI for the year. An individual making $40,000 a year would have to exceed $4,000 ($40,000 x 10%) in expenses to deduct. For taxpayers over 65, the requirement will remain at the original 7.5% through 2016.
These recent changes will make it harder to write off your medical expenses in the 2013 tax year, so start taking steps now. It may seem a bit overwhelming, but try to itemize your medical expenses throughout the year. Ask your pharmacist to provide you with a printout of each prescription you had filled in the past year, or create an online account to gather this information.

Primary Care Doctors and Medicaid payments

Medicaid is expected to be in higher demand than ever as a result of health care reform. To incentivize doctors to continue to accept Medicaid patients and to attract new doctors, the health reform law requires states to make payments to certain physicians who are at least equal to those that are received for Medicare patients.
In 2013, the increase in Medicaid fees to certain physicians for primary care services will be an unprecedented 73% (on average), according to the Kaiser Commission on Medicaid and the Uninsured. For 2013 and 2014, the federal government will be fully funding the cost of Medicaid fee increases.
Not all doctors are eligible to receive an increase in Medicaid payments. Doctors specializing in the following fields qualify: family medicine, internal medicine, and pediatrics.
It remains to be seen whether higher Medicaid payments to doctors will continue after 2014. The ACA does not clarify this. States may just revert to paying whatever they see fit as long as it complies with general Medicaid requirements of 42 U.S.C. 1396a(a)(30)(A), which requires that states “assure that payments are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population.”

Funding to State Medicaid Programs

You may have heard talk of the Supreme Court’s ruling on Medicaid — the program providing health care to low-income Americans. Medicaid programs are run separately by state under guidelines set by the federal government. On average, the federal government foots about 57% of the bill per state to keep the programs running.

Beginning on January 2014, under the ACA, Medicaid eligibility would expand throughout the country, making health insurance available to anyone (regardless of age or condition) with an income under 133% of the federal poverty level. As of 2012, that level was $14,856 a year. With this expansion, 17 million more uninsured Americans would receive coverage. The federal government would initially cover the entire cost of Medicaid expansion and each state would be required to pay back 10% after three years or else lose their existing Medicaid funding.

After challenges from 26 of the states, the Supreme Court ruled that it was indeed unconstitutional for the law to take away existing funding and subsequently allowed individual states to opt out of the law’s Medicaid expansion if they so decide. States consenting to Medicaid expansion will receive funds from the federal government to cover 100% of costs, decreasing to 95% in 2017 and 90% in 2020.

Children’s Health Insurance Program (CHIP)

CHIP is designed to help children whose families do not have health insurance, but make too much money to qualify for Medicaid coverage. It has been extremely popular since it was signed into law back in 1997. The new and improved CHIP, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) was signed into law in 2009. In addition to reauthorizing the program, CHIPRA made more funds available for the program.
Both CHIP and Medicaid are state-run programs that are funded jointly with the federal government. The amount that the fed contributes to a state’s CHIP program (the federal matching rate) is typically around 15 percentage points higher for that state’s CHIP program than for its Medicaid program.
The ACA states that the eligibility requirements for CHIP will remain the same throughout 2019. Funding is also going to be dramatically increased for the program; the federal matching rate will go up by 23 percentage points for each state. This will make the average federal matching rate 93% by 2015. In addition, the ACA provided $40 million in federal funding to spread the word about CHIP and Medicaid in order to get more people to enroll.
Sean O’Connor is media content manager of GoHealthInsurance (www.gohealthinsurance.com).

Chiropractic – The Hidden Benefits of Chiropractic and Acupuncture

by George W. Vieth, Jr. and Joel Stevans, D.C.

The direct and indirect cost of pain for American businesses is under appreciated. According to the Institute of Medicine, persistent pain affects 100 million U.S. adults annually. This means that approximately half of all adults live with some level of pain. More importantly for employers, persistent pain is estimated to cost a staggering $300 billion annually in absenteeism and lost productivity.

Spinal pain and headaches are the most common sources of loss. These conditions are pervasive and affect employees in every industry. Furthermore, the American Academy of Pain Medicine reports that most of the pain-related lost time is caused by reduced performance while employees are on the job; workers with persistent pain are significantly more likely to report activity limitations. Given the affect pain has on workforce performance, employers need to understand that health care benefits are available to mitigate these costs at an affordable price.

Two health care services that are proven to be effective in treating these conditions, chiropractic and acupuncture, are too often missing from an employer’s benefit coverage. The National Institutes of Health (NIH) has found that procedures performed by chiropractors relieve suffering from back and neck pain, headaches, and upper- and lower-extremity joint conditions like knee, hip and shoulder pain.

The NIH also reports that acupuncture is effective in treating a wide range of persistent pain conditions. One study showed that acupuncture provides pain relief and improves function for people with osteoarthritis and serves as an effective complement to treatment by traditional physicians. In addition, the NIH reports that acupuncture is also useful in treating back pain, neck pain, and carpal tunnel syndrome. Based on the strength of the scientific evidence, many conventional medical providers recommend the use of chiropractic and acupuncture. The American Pain Society and the American College of Physicians recently issued a clinical practice guideline in which they recommended that both chiropractic and acupuncture services be considered as treatments for back pain.

Despite growing evidence to support the use of chiropractic and acupuncture services for the common causes of pain, most people still pay for these services out-of-pocket. This is true even for those covered by group plans because too often the medical plan does not cover chiropractic and acupuncture services. In other instances, group plans only offer these services through discount arrangements that don’t facilitate the access needed because the discounts are minor.

Insured coverage for chiropractic and acupuncture offers employees effective low cost alternatives to more traditional treatments. Absent this coverage, individuals in pain end up in expensive drug and surgery regimens, often after multiple sets of CT scans and MRIs. It is generally recognized that the initial step in treating pain should be a course of conservative care, such as chiropractic, acupuncture or physical therapy. Compared to spinal fusion surgery at rates of $50, 000 to $100,000 per procedure, the $2 to $6 monthly premiums and $20 office visit co-pays for chiropractic/acupuncture services are extremely cost effective. And while surgery isn’t always the trade-off, chiropractic and acupuncture are much less expensive than more conventional care based on drugs, injections, diagnostics and surgery. Underwritten and self-funded groups can use chiropractic and acupuncture to lower their medical costs and improve their claims experience. And time not spent recovering from more invasive procedures benefits groups of all sizes, not to mention the decrease in employees’ out-of-pocket costs from avoiding more expensive treatments. Despite these advantages, brokers may be reluctant to suggest chiropractic and acupuncture benefits because they are unfamiliar with these services. We offer this primer to the broker community as a brief introduction to chiropractic and acupuncture services.


Chiropractic is a health care profession that focuses on the relationship between the body’s spinal structure and how its misalignment causes pain and dysfunction. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments, often referred to as manipulations to the spine or in some cases to other parts of the body with the goal of correcting alignment problems that induce pain and disability. Correct spinal alignment also supports the body’s natural ability to heal itself. Applied most frequently to the spine, a chiropractic adjustment involves using the hands or a device to apply a controlled, rapid force to a joint that is misaligned or not moving freely. The goal is to increase the range and quality of motion in the area being treated.

During the initial visit, chiropractors typically take a health history and perform a physical examination, with a special emphasis on the spine. Other examinations or tests, such as x-rays, may also be performed. If chiropractic treatment is considered appropriate, a treatment plan is developed. During follow-up visits, chiropractors may perform one or more of the many different types of adjustments and other manual therapies used in chiropractic care. The typical course of care requires about six visits over several weeks. Chiropractors may also combine the use of spinal adjustments with the following treatments:
Heat and ice
Electrical stimulation
Relaxation techniques
Rehabilitative and general exercise
Counseling about diet, weight loss, and other lifestyle factors
Chiropractic colleges accredited by the Council on Chiropractic Education (CCE) offer Doctor of Chiropractic (D.C.) degree programs. Admission to a chiropractic college requires a minimum of 90 semester hour credits of undergraduate study, mostly in the sciences. Chiropractic training is a four-year academic program that includes both classroom work and direct experience caring for patients. All states require completion of a Doctor of Chiropractic degree program from a CCE-accredited college. Examinations administered by the National Board of Chiropractic Examiners are required for licensing and most states require chiropractors to earn annual continuing education credits.
In the United States, chiropractic is generally considered a complementary health practice. A recent study showed that about five percent of adults in the United States use chiropractic services annually but the use of these services was greater than 10% in smaller communities. Many people who seek chiropractic care have low-back pain. People also commonly seek chiropractic care for other kinds of musculoskeletal pain (e.g., neck, shoulder), headaches and extremity (e.g., hand or foot) problems. Among those who had used chiropractic for back pain, nearly 70% reported great benefit from their treatments.


Acupuncture is among the oldest healing practices in the world. In the United States, where practitioners incorporate healing traditions from China, Japan and Korea, acupuncture is considered part of complementary and alternative medicine (CAM). The term “acupuncture” describes a family of procedures involving the stimulation of anatomical points on the body using a variety of techniques. We don’t know precisely how acupuncture works, but one theory is that pain-relieving chemicals (opioids) are activated in the brain when anatomical points are stimulated. The acupuncture technique that has been studied most often involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or electrical stimulation.

A leading report from a Consensus Development Conference on acupuncture stated that thousands of acupuncturists as well as specially trained physicians and dentists are using acupuncture for relief or prevention of pain and for various other health conditions. An estimated 3.1 million U.S. adults used acupuncture in the previous year, according to the 2007 National Health Interview Survey.
During the first office visit, the acupuncturist may ask about the patient’s health, lifestyle, and behavior. Based on the patient’s condition, an acupuncture practitioner will select specific points on the body to stimulate — most often by inserting thin needles through the skin. In traditional Chinese medicine theory, this is believed to regulate the flow of “qi” (vital energy) along pathways known as “meridians.” People experience acupuncture differently, but most feel no pain or minimal pain as the needles are inserted. Some people feel energized by treatment, while others feel relaxed. Treatment may take place over several weeks or more.

Although available as a standalone benefit, acupuncture benefits are most often offered with chiropractic benefits. An acupuncture benefit will add 25% to 50% to the cost of a chiropractic plan. Patient co-pays are low — similar to those of chiropractic visits.
Most states require a license to practice acupuncture; however, education and training standards for obtaining a license vary from state to state. In California, an acupuncture practitioner must graduate from a California Acupuncture Board approved school after completing 3,000 hours of education in biomedical sciences, traditional Chinese medicine, and clinical training. Before their acupuncture training, they must also complete a minimum of 60 semester hour credits of undergraduate study. Following their formal training, an acupuncture practitioner must pass a written licensure examination administered by the California Acupuncture Board. Finally, all acupuncture practitioners must complete 50 hours of continuing education every two years to maintain their license.
In a benefit landscape of high cost trends, ever increasing premiums, and skinnier benefits, offering chiropractic and acupuncture coverage to your groups is an opportunity to offset this tide. For a few dollars per month, your groups can have access to effective therapies that will reduce overall medical expenses while providing low cost pain relief.
George W. Vieth, Jr. is CEO of Landmark Healthplan of California. Landmark Healthplan of California offers a wide range of insured and self-funded group chiropractic and acupuncture benefit plans through its statewide network of 1500 credentialed providers. Landmark is a Knox-Keene licensed specialized health services plan that has been providing and managing complementary medicine in California since 1985. Landmark is the only licensed plan offering chiropractic and acupuncture benefits directly to employer groups in California. For more information contact Michelle Kulton at 916.569.3319 or mkulton@LMhealthcare.com or visit www.LMhealthcare.com.
h2>Long-Term Care – When the Need for LTC Coverage Hits Home
by Maxwell Schmitz
Long-term care insurance is a compelling product both statistically and personally.
There are a few major talking points that every advisor should address with their clients.
10,000 people turn 65 every day (NY Times 12/2011).
70% of people over age 65 will experience a long-term care event.
The average cost of private-room nursing homes is up to $100,000 a year in the Bay Area.
The cost of part-time homecare is $50,000 a year in the Bay Area.
The cost of care has inflated at a rate of approximately 5% compounding every year.
California has some of the oldest communities per capita in the U.S.

Remember that bathing and dressing are typically the first two activities of daily living (ADLs) to be lost. Younger family members often think they can assist with an elder’s eating and transferring, but these are the last ADLs to go. If an aging relative reaches that point, then it is likely that continence and toileting are already compromised. Make sure your clients and their children are prepared to acknowledge this before they become the caretakers.

Most young prospects will give these statistics a thoughtful nod, and then blissful ignorance and invincibility will recover their influence over the client’s financial plan. That’s when the personal stories come in handy. Almost everyone has been affected, and you must have a compelling story of your own. Personal stories stick. Don’t be afraid to ask about the gory details. If you haven’t felt the confusion and helplessness of a long-term care event, then feel free to use someone else’s story because they are closer than you think.

Here’s mine: Grandma Liz was diagnosed with Parkinson’s Disease in 1987, the same year I was born. My dad elected to stay close to his hometown in a sleepy corner of the San Francisco Bay Area. My parents and I were close enough to drop by regularly when she first needed care. The story begins when the stairs at my dad’s childhood home became too difficult for Grandma Liz to navigate on her own. The mortgage on her home was almost paid in full after she collected the life insurance benefits from my grandfather’s death a few years earlier. An elevator was not a realistic option. Grandma Liz had to downsize. We sold my grandfather’s home.

She found a new house in the same neighborhood, still just eight miles from us. Unfortunately my parents were unable to meet the rigors of caregiving when she finally required more comprehensive LTC services. After all, my folks had a business to run, a three-year-old, and another baby on the way. Bathing grandma was not on the list of morning chores, as is the case with most families. The recent move left enough in the bank to utilize some in-home services.

Grandma Liz required around-the-clock care at this point. After a cycle of bad caregivers, we eventually found two lovely women to split the burden and assist at a more affordable rate. Even still, it felt like barely any time passed before the bills began to add up and we were forced to sell her new house.

We bought a mobile home for Grandma Liz in a trailer park off the freeway. She was willing to compromise the location of her new home, but unwilling to waver on the type of care. Homecare services made her feel as independent as possible, and that was not up for negotiation. “Nursing homes are for old people,” she would say; she was only 61.

After a few short years, Grandma Liz was having trouble cooperating with the caregivers. She could no longer assist in lifting herself up in the mornings or to go and use the restroom. We had to hire a bigger (and meaner) caregiver to help Grandma Liz as she continued to perform less and less of her activities of daily living. She eventually opted for a nursing home instead of dealing with her new attendant. She had grown weary of all the moving, and the money was close to running out. We decided that a nearby Medi-Cal facility was our best option.

Grandma, grandpa, and everyone in my family have great pride in our self-reliance and responsibility. The idea of artificially spending-down my family’s hard-earned dollars in order to qualify for welfare was a repugnant concept. She wanted to be as independent as possible. Nonetheless, we needed to help Grandma Liz transition to the Medi-Cal facility so that she would not have to move locations after the money was depleted. I was eight years old.

A strange roommate and an apathetic staff greeted her. The permeating smell of urine and antiseptics loomed over every interaction from that point forward until the end of her life. This was the safety-net system. While Medi-Cal softens the fall for many families, it wasn’t long before we began to feel trapped in the net. The disease had left my grandmother confused and angry most of the time, but the Medi-Cal facility took her state to the next level.

I had reached a point where I no longer wanted to visit at all. At age 10, I remember lobbying my six-year-old sister to strike a fuss with me when we were scheduled to visit Grandma Liz at the nursing home. I had no apparent regard for the fact that these were my grandmother’s last days on earth, and I did not care enough to see her. She died just before the money ran out.

This guilt of avoiding my grandmother has consumed me at times, especially given the nature of my profession. There may have been a way to stop the helplessness of this situation. LTC insurance products did not cover homecare benefits before she was ineligible for coverage. However, they do now, and homecare has become an inestimable help for millions of people that face similar situations on a daily basis. It is difficult to think of all the families undergoing a comparable event because of poor financial planning.

My family’s situation is not unusual. Confusion and helplessness are common themes that weave themselves into LTC events. An LTC policy could have guarded us against some of the austere actions we had to take in order to continue care for Grandma Liz. Any structure would have helped even an itemized procedure of the events to come. For example: 1. Downsize her home, 2. Seek a compassionate homecare attendant, 3. Downsize again, this time to a mobile home, 4. Take her to a Medi-Cal facility.

The comfort of knowing what was going to happen next probably would have eased many of my parents’ fears about each ensuing step of the process. Today’s long-term care policies offer a grossly undersold feature called “care coordination.” The question of “What’s next?” does not have to be part of the equation. Instead, you can focus on “How can we keep Grandma the most comfortable?”

The debate over whether or not to sell Grandma Liz’s home was an especially depressing dilemma in our episode with LTC. No one wanted to let go of the memories associated with that property – the last home my grandfather ever owned. An LTC policy could have paid for her benefits and a home modification. Instead we were cornered into the unfortunate situation of selling the home and paying for care with the dollars we saved by downsizing.

The absence of time in the day to assist with ADLs is a problem faced by millions of caregivers across the country, including those that are surrounded by supportive family. In Grandma Liz’s case, my father was the only local relative. His sister lives in Oregon, and Grandma Liz was an only child, so nieces, nephews and cousins were out of the question. This left only my parents to keep watch over my grandmother. But it is an enormous sacrifice even for those that are able to rotate care among family members. Time is precious, and often times that leads to financial hardships, but not only for the person who needs care. LTC is most difficult for the family that must sacrifice their time at work, other obligations, and time with each other.

The psychological hardships are the most taxing. Grandma Liz loved to have us come by and say hello, but she would not have allowed any of her relatives to see her in an “indecent” setting. Many relatives find themselves bathing and dressing their older family members. These families begin to lose their ability to look each other in the eye in a normal way. The embarrassment and shame of being cared for was not taken into consideration before the LTC event began, and it has taken its toll on families’ well-being.

The polite and respectful homecare-givers were the single best episode of Grandma Liz’s LTC experience. However, it took years to find them, and they were only able to do so much before Grandma Liz’s needs required more intensive support. Compassion was not a common character trait among the temporary caregivers, or even those at the Medi-Cal facility. A care coordinator provided in an LTC policy would have provided a much more streamlined process to discover the right homecare aide.

The last resort was the nursing home. This is still the case today. Most LTC recipients want to cling to their final days of independence, and the move to a nursing home signifies the end of their abilities — the end of their life. It is completely natural to resist. Grandma Liz verbally assigned herself to a nursing home and her health severely declined because that was the moment that she began to give up — the beginning of the end. She had been fighting Parkinson’s for almost 10 years at that point, and it truly was a daily battle. With an LTC policy, she would have been able to continue homecare with a provider that could suit her needs. Or perhaps she would have been better in a nursing home with more of a community atmosphere. Neither of these were options without an LTC policy.

Instead, we were filtered into the welfare system. My grandfather was a planner, and both he and my grandmother greatly believed in helping oneself by having the proper plans in place to see to it. Government dependence was not part of their vocabulary. Nevertheless, it still became a huge part of our lives and dictated the quality of care that would be afforded to our situation. LTC would have given us more options. We would have been able to dictate the quality of care.
There is a certain amount of guilt in learning our lesson after the fact. It’s the guilt in knowing that we will have more comfortable care since we saw the ugliness associated with a lack of planning. It’s the guilt of feeling irritated and resentful with every visit. It’s the guilt of now knowing that there is a way to plan for these events, and discovering that it was right under our nose all along.
The products are available now. Most families can qualify now. The problem is that few consumers know that these products exist, and those few that are aware are usually unassisted by a broker before it is too late to qualify. Give your clients the opportunity to explore LTC insurance before they have to sell their home. Give them options before they are caught in the safety net.
Maxwell Schmitz (CA lic 0G86760) is brokerage manager with DI & LTC Insurance Services in San Rafael, Calif. For more information, call 800-924-2294 or visit www.DI-LTC.com.

Disability – Making a Difference with Disability Management Programs
a Case Study

by Alison Daily
From 2008 to 2010, California workers drew more than $8 billion in State Disability Insurance (SDI) benefits for non-work-related disability claims, according to the Employment Development Department. Employers also contend with absenteeism and presenteeism, higher health care costs, and low productivity.
Employers are looking for benefits to help cut costs while keeping productive employees on the job. That’s why this is a time of tremendous opportunity for brokers.

A Disability Management Program In Action

The City of Carson offers a case study in how to implement a solid disability management program. City employees keep this culturally diverse industrial center running smoothly. But, as with any organization, injuries, illnesses, and other problems happen — often causing employees to take short-term or long-term leaves. To lower the risk of losing valuable employees to disability-related leaves, the city partnered with a disability insurance provider devoted to disability prevention. This partner immediately started helping the city identify opportunities to keep employees on the job. It is important to choose a carrier that has expertise in disability management programs and is committed to preventing disability-related leaves.

The Office Worker

One City Hall employee struggled with back pain and neck stiffness due to the repetitive motion required by her day-to-day work. She often missed work to get medical treatment for these problems. An on-site consultant performed an ergonomic assessment of her workstation and the revamping began as follows:
Modified the keyboard with an adjustable platform, allowing it to move side-to-side and up and down
Positioned the computer monitor to reduce neck pain.
Designed a special air filled chair cushion to relieve lower back pain and neck stiffness.
The intervention greatly relieved her pain and dramatically reduced the number of workdays she missed.

The Code Enforcement Officer

Part of a code enforcement officer’s everyday job is to get in and out of their vehicle to enforce municipal codes. This part of the daily grind caused problems in one officer’s lower back and legs. An on-site consultant helped make safe modifications to the vehicle to avoid further distress on his back and legs.

These modifications, many of which were relatively inexpensive, allowed the employee to stay at work, safely and productively. They also saved the city costs associated with losing productivity as well as hiring and training a new employee.

Nearing the two-year mark, human resources officer, Duane Munson, can attest to the benefits of the disability management program, “In such a short time, we’ve already seen success. We’re very optimistic about the future.”

Workplace improvements don’t just stop at ergonomic solutions. The consultant, who is a routine visitor at Carson City Hall, regularly suggests ways to prevent or reduce injuries and provides general assistance with claims services or other problems.

For example, the consultant recently recommended that the city install special software for employees with carpal tunnel syndrome. The software reminds employees when it’s time to take a break. “These pop-up messages encourage you to back away from your workstation and do things, such as hand stretches. For task-oriented individuals, this process works really well and definitely helps lessen the likelihood of the syndrome worsening,” said Munson.

By offering a versatile disability management program, brokers can help clients strengthen their benefit offerings to attract and retain top talent, boost employee morale and, most importantly, maintain productivity during still uncertain times. Offering clients a quality disability program not only leads to long-term cost savings, but also is very likely to develop into a long-term partnership.
Alison Daily is director of The Standard’s Workplace Possibilities program and is responsible for overseeing the clinical and return-to-work staff. The Workplace Possibilities program is a unique, proactive approach to helping employers prevent and manage disability in the workplace. By identifying opportunities to keep employees who may be at risk of a disability on the job and get those who go out on disability back to work sooner, employers can realize rapid and measurable reductions in disability-related costs. For more information, Daily can be contacted at alison.daily@standard.com. The Standard is a leading provider of financial products and services.

Life Lines – Are the Singles Market and Life Insurance
Technologies the Key to More Life Sales?

For this issue we look at three different takes on the current status of Life Insurance in today’s market. Starting with the singles market.

A Life-Changing Decision for Single Parents

by John T. Harmeling
Although 93% of adult Americans say it’s important to have life insurance coverage, 25% of primary wage earners don’t have a plan in place to provide for their family if they die. Smart producers can improve their sales pipeline by focusing on a segment of consumers who have a greater need for the product.

One segment that has a greater need for life insurance products than, perhaps, any other is single parents. If something happens to a single parent, there is no second parent to provide for their children.

According to the U.S. Census Bureau, there are approximately 13.6 million single parents in the United States. Those parents are responsible for raising 21.2 million children, which is about 26% of children under 21 in the United States. Eighty percent of single parents are mothers. But, single father homes are the fastest growing type of family situation, with the number of single fathers having grown 60% in the last 10 years alone, according to usalegalcare.com.

Understanding Single Parent Concerns

Raising children and providing for them is difficult, especially when only one parent is involved. A single parent must juggle work, childcare, chores, children’s activities, finances, and whatever other challenges that single parenthood may bring. The financial responsibility that comes with raising children as a single parent can seem overwhelming.

For many single parents, finances are tight and they may live from paycheck-to-paycheck. Unless they manage to work two jobs, single parents have only one income, which must be enough to support bills like rent and utilities, as well as the costs of raising a child. These costs include extra groceries, clothing, day care, and much more.

According to the U.S. Department of Agriculture, the cost of raising a child from birth to age 18 for a middle-income family averaged $226,920 in 2010 (not including college). That’s up nearly 40% (more than $60,000) from 10 years ago. Just one year of spending on a child can cost up to $13,830, compared to $9,860 a decade ago.

Depending on a single parent’s situation, this financial obligation may be one that no one else can meet. If something happens to this parent, other family members may not have adequate resources to care for a child in the manner the parent would want.

Addressing Their Needs

The best thing they can do is purchase life insurance to help ensure that their children can grow up without financial concerns and can go to college in case of a single parent’s death. However, a single parent will need to do this in a way that does not create a financial burden on their family right now.

A policy is needed to care for the children and pay for funeral costs. Funerals can be a financial hardship for families. The average adult funeral cost totaled nearly $8,000 in 2010, according to the National Funeral Directors Association.

Perhaps more than anyone else, single parents need a trustworthy advisor to get the best coverage for their money and be responsible for ensuring their children receive the payout. In some cases, single parents had life insurance when they were married. But they need help choosing a new policy now that they are divorced or widowed. They may look to their agent or broker to advise them on the types of life insurance and what would best meet their needs.

Providing Smart Options

Life insurance can be an important element of a lifetime financial plan. Purchasing a plan early can give single parents a financial edge over those who go through their early adult years without thinking about how they might take care of their family. People are often at their healthiest in young adulthood, which can help them secure a policy with a lower premium. Whole life policies can be a good early investment because premiums typically remain fixed and a young policyholder is more likely to be able to lock in a low rate than one who’s middle-aged.

The following are other reasons for single parents to consider a whole life policy:
The increase in cash value isn’t subject to income tax while the cash remains in the policy.
They can take out a loan on a whole life policy’s cash value to contribute to a down payment on a home or meet retirement or college tuition needs.
A policyholder who gets married and wants to increase the amount of coverage can build on the current policy instead of buying a policy later in life when it can be more expensive.
While term life insurance may provide the most coverage for the least amount of money, whole life insurance is better if the individual can afford it, since it’s permanent. A combination of both is also a good option. For example, single parents may elect to purchase a small whole life policy that provides coverage later in life for burial expenses, and a larger, less expensive term life policy to cover their children in the event of their death until the children are old enough to care for themselves.

Bridging Coverage Gaps

It’s also important for single parents to know that many employers have cut benefit offerings, including life insurance. These changes can leave them with gaps in coverage. They are often unaware that they no longer have an employer-paid life insurance plan. Many of the adults who have life insurance rely solely on their employer’s group coverage, according to a 2011 LIMRA study. In fact, the percentage of adults owning group life insurance has surpassed adults with individual life insurance, and people insured only through group life insurance have the lowest average amount of coverage.

Voluntary life insurance plans put the power back in the employees’ hands, enabling them to make decisions that best fit their needs. It’s a benefit solution for employers as well because offering voluntary coverage doesn’t add benefit costs to the company. Voluntary life insurance plans have become more attractive over the past few years. For example, consumers have the option to purchase whole and term life insurance policies, including a juvenile life plan to be sure they are adequately covered and that their insurance is not tied to their employer. That means that if policyholders of voluntary life insurance leave a job or retire, they can take their policies with them without an increase in premiums — a feature that all workers will appreciate.

While life insurance is an important part of financial planning for everyone, it’s especially important for single parents. They need the peace of mind that their children will be cared for if they’re gone. But with financial struggles and possible cut backs in employer-provided coverage, they also need options they can afford. The agent or broker is in a position to serve as educator and advisor, helping this particular market segment get the right coverage for them and their children.
John T. Harmeling is Aflac’s senior vice president of Worksite Marketing. Harmeling is responsible for developing and driving growth strategies in Aflac’s worksite segment, overseeing integrated sales and marketing programs across all sales channels, and extending the company’s efforts to attract and retain customers. For more information about Aflac, call 800-99-AFLAC (1-800-992-3522) or e-mail addbenefits@aflac.com.

To Sell Life Insurance Technology, Sell the Benefits

by John West
Ask any broker how they built a successful relationship with a client and they will probably tell you that they established a rapport around a fundamental sales tactic: problem-solving.
The best life insurance brokers not only help a client meet the basic need to provide essential coverage, but they also listen to the smaller problems that arise during their interactions. You can uncover sales opportunities when HR managers tell you about administrative problems, such as reports that take longer than necessary to pull or the burden of too much paperwork.
Brokers can help clients use electronic technology to solve administrative or procedural issues that they are having with their current life insurance carrier. Electronic life administration services can help clients with routine problems, such as updating their enrollment and managing their record-keeping and billing processes.

The streamlined efficiency that electronic administration services can offer allows brokers to be more effective in their touch points with clients. Instead of just reacting to clients’ administrative problems, brokers can work on solving bigger challenges, strengthening relationships, and ensuring that clients will be part of their customer base for years to come.

Identifying Pain Points

Many carriers offer online technology that streamlines administrative procedures and reduces the time it takes for HR departments to process claims. Clients may bring up the administrative hang-ups they are having with their current provider when talking with their broker at a quarterly touch point. This can allow brokers to have a candid conversation with each client to dig deeper into the problems they may be experiencing.

To begin the discussion about the benefits of online technology, brokers should provide an example of how it can help them. However, offering electronic technology as a one-size fits-all solution may overwhelm a client and weaken a sale. To be effective, the technology should specifically address the client’s concerns and meet their needs. Listening and understanding a client’s chief complaint about their current method of administering life insurance benefits can help brokers identify an appropriate solution and strengthen a relationship.

Complaint 1: Enrollment — “I Can’t Keep Up With the Influx of New Employees”

HR departments can leverage enrollment technology that allows employees to sign up for coverage and input medical underwriting information through an online system. HR can track additions easily in their system since they receive automatic notifications when the information is entered.

Electronic technology creates a level of automation not seen with paper-based systems and allows HR managers to identify where an employee is in the enrollment process by consulting their online portal.

Complaint 2: Up-to-Date Record-Keeping — “My Desk Is a Mess of Piled Up Paperwork”

Record-keeping functionality is one of the most popular features of many electronic life administration services. Since a large amount of paperwork is often required with routine changes, brokers hear that their clients are nervous about keeping sensitive information, primarily beneficiary forms, in their office.

Electronic life administration services keep a plan participant’s information current by offering online beneficiary tracking and recognizing when an employee enters or updates existing information. Employers can use the process of transitioning to an electronic platform as a way to remind employees to update beneficiary designations and start fresh in the system. Updates can be made as soon as the product is installed.

Once the system is up and running, an annual enrollment or benefits evaluation can offer an excellent opportunity for employees to consider the scope of their benefits or any changes that may need to be made.

Complaint 3: Billing — “It’s Difficult to Pull Accurate Reports”

Some electronic life administration services can simplify benefit plan administration for HR departments by increasing accuracy and efficiency. HR departments can view payment history, review billing information by billing division, and access details for any billing cycle. In addition, if a plan participant’s personal information changes, updates can be made easily online.
HR departments also can pull claim status, payment, and experience data to quickly confirm when benefits were issued. Billing modules are updated continually with current participant data, which is reflected in payroll fees and extracted lists of premiums on a payroll-by-payroll basis.

Broker Success Factors

Technology is becoming more important to the life insurance industry as the Millennial generation matures and represents an increasingly large pool of potential clients. The oldest Millennials are turning 30 while the younger members are embarking on their future career endeavors.

This generation has been on the Web since they were able to write their names, and they expect to get information quickly and seamlessly. Tech-savvy Millennials are the first generation in history to view Internet technology as an everyday part of their lives, not as an innovation of the digital era. This generation’s comfort with technology enables a broker to offer solutions that can help maximize enrollment, such as online enrollment modules.

No matter what challenge the electronic service will address, the most successful brokers fully educate their clients on the up-front investment that’s needed to get the system up and running. This investment is critical to reaping maximum benefits down the road.

For the best results when implementing plan technology, the employer and the carrier should have an in-depth conversation. Then both parties will participate in a discovery process, during which the carrier and the employer work collectively to receive and input as much quality data as possible upfront.

It takes time to set up electronic enrollment systems and diligence to maintain them, but putting time in early will greatly benefit a client later. The more transparent brokers are with their clients about the implementation process, the better off both parties will be.
Brokers should drive expectations and reinforce the importance of switching to a carrier with online services, but they do not need to know the ins and outs of how the technology works. Carriers will help shepherd the client through the process, delivering timelines and implementation schedules, working to train administrators on the new systems, and troubleshooting problems. The broker’s responsibility is to help the customer understand the best way to use the technology to help their business run more effectively.

Alleviating Administrative Stress Is Key To Transition

Brokers who sell life insurance products have turned administrative stresses into sales successes by providing clients with life insurance products that are equipped with electronic technology. By tailoring solutions to a specific client’s pain points, brokers can demonstrate the extent to which they know a client’s business.

These solutions also can allow the broker and the client to focus on other priorities; brokers can continue to build relationships with their clients while clients can focus on other job duties. Working collaboratively with a client is key to making this transition work. The more information a broker can get up-front helps sets up the client and broker for ongoing success after the transition to an electronic product.
John West is director of product management for Standard Insurance Company (“The Standard”). He is responsible for development and enhancement of The Standard’s group insurance offerings.
The Standard is a leading provider of financial products and services, including group and individual disability insurance, group life and accidental death and dismemberment insurance, group dental and vision insurance, absence management services, retirement plans products and services, individual annuities and investment advice. For more information about The Standard, visit www.standard.com.