Health care benefits are becoming increasingly important in the struggle to keep good employees. Are you aware of all your options? It seems like things were so much simpler just a few years ago. At one time most businesses had the same insurance company. You remember: the old 80/20 indemnity plans with the quarterly deductible? The patient paid 20 percent of the office visit plus the quarterly deductible, and the insurance provider paid the remaining 80 percent. I don't know if it was good or bad, but it sure seemed a lot simpler.
A major chore
Like most business owners today, I find myself spending large amounts of time shopping for health care plans. In the past, several insurance companies have told me that our company has reasonable rates considering the volatile market. Then again, we have always shopped annually for health care insurance. In a sense, we have always tried to stay on top of it.
In addition, we enlist the help of a broker who obtains quotes from several different companies each year. Even so, every year I am shocked over our renewal rates. In the past, they have gone from chunky 12 percent to whopping 30 percent increases. These increases are tough to stomach for both the employer and the employees. Currently we pay 50 percent of our employee's health care benefit. Even so, how do you tell your employees every year that their weekly pay just took another $20 hit? How will the business cover its portion, a $5,200 annual increase? Let me tell you, it's just not easy. In the end, it comes down to several key issues.
At first blush, the health care market can seem like a labyrinth of nightmares. There are many companies to choose from and each company has a variety of plans and configurations.
One company will offer a two-tier rate as single vs. family coverages. Other companies will offer three- or four-tier plans that include the two-person households (single plus one). Once you know the rate, the business and employees can figure their annual costs. That's the easy part. The hard part is choosing a plan everyone can best live with.
What's your style?
You see, it's all a matter of how much you want to pay in addition to your monthly premium. Or as the insurance industry would say: how much do you want to co-insure? Can you live with a plan that requires referrals to see specialists? Do you mind having to go through a gatekeeper (primary care physician) for specialist referrals? Can you live with a $20 co-pay, or can you afford the plan with the $15 co-pay?
Will your family have to go to the hospital this year? If so, can you handle the first $2,000 out-of-pocket expenses, or can you afford the more expensive plan with the $250 hospitalization cost?
Do you and/or your employees require many maintenance prescriptions on a regular basis? Can you handle a formulary (drug) benefit of 10/25/40? Can you really afford the plan with the 10/20/35 formulary? It's a lot to think about.
Don't be surprised if the insurance company makes you fill out a questionnaire concerning details of how you pay your insurance. A common question on this form is what percentage your business pays toward employee health care. Typically the insurance companies will mandate that the business pay at least half of the family plan's premiums and a third or more of the single plan's premiums.
Why would the insurance company care what portion your business pays? It all has to do with the insurance underwriters and how they determine risk ratios. A business that pays for half of the health care benefit will tend to have a better ratio of healthy subscribers. The logic is that more people will sign up because a larger amount is employer paid, and that means more healthy people in the plan. But when the employee has to pay more, those who know they are more likely to need health care coverage will tend to sign up more readily. This is because they have no choice but to purchase the coverage. This ends up costing the insurance company more money.
Other questions on the questionnaire may ask about the number of "eligible" employees who are currently not on the plan. This normally means other full-time employees who are obtaining health care elsewhere, such as through their spouse's employment. Again, the insurance company wants to know about possible future risk. The insurance company knows that they may be on the hook for providing coverage if an employee's spouse suddenly loses his or her job or heath care. Remember that these insurance companies hire whole staffs of smart people to ensure they are covering all bases.
Unanticipated increases
You should be made aware of a new tactic that some health insurers are trying this year. When we received our recent health care renewal, our main concern was both the coverage and the rates for single and family. We have had the single/family two-tier rate for many years now.
Unbeknownst to me, the insurance company decided to slip in an additional rate this year. It was so surprising that even my health care broker had never heard of it. After choosing our renewal plan we were stunned when we received our first bill.
Although we had selected a two-tier plan, we actually got a three-tier plan. How can they do that? Here's how: for the past several years my parents have had Medicare Part A, as well as the company's health insurance plan. Suddenly, in this year's renewal, our insurance company had decided to charge a higher rate for my parents. That's right: a premium that is greater than the normal single or family rate. It comes down to about an additional $45 for each of them, adding $90 a month to our monthly statement.
When I called the representative at the insurance company, he directed me back to my rate quote sheet. Sure enough, down at the bottom, was a statement that said that we had two "Medicare Active Employees." On a subsequent conference call, my insurance broker and I challenged the account representative about this new unannounced rate structure.
The account representative had a few interesting explanations. He stated that in the past, overall group rates were higher to make up for the "older high-risk" members on Medicare. The insurance company had decided to spread out the risk factor in a more realistic way. In other words, give more premium burden to the Medicare-active members.
That excuse did not seem to wash, and it led to another question. Federal law dictates that Medicare is the primary provider when a Medicare active participant is on a plan with 20 members or less. That being said, why would the insurance company charge more if Medicare were the primary responsible provider?
The representative's answer was interesting: he said that a person who is on Medicare and still on a private plan is considered a "red flag" with the underwriters. Why? Because underwriting presumes that member must have a high-risk health factor if they need both Medicare and a private plan.
Needless to say, we did not get very far in the discussion. Our broker believes that they quietly pushed this new three-tier structure through in hopes of catching most subscribers off-guard. After all, it would have been nice for them to bring this change to our attention before we chose the renewal plan. Then we would have had a true picture of the coming year's cost.
Don't forget details
Ask your insurance provider how they pay the doctors within the plans. Most plans now pay each doctor a reduced "Fee For Service." However, some HMO plans pay doctors via "Capitation Methodology," in which the doctors have already been allotted payment in advance. The insurance company sets up a large pool of funds for the doctors. In essence, the doctors have been paid without seeing any patients. Each time a patient comes in for service, the doctors are using up the revenue they have already been allotted.
In addition, the insurance companies can offer incentives to doctors that stay within the pool amount for the year. Doctors that over-utilize care with too many specialists referrals may not receive the dividend payment. Some patients and physicians argue that this method reduces the utilization of services and even compromises patient care. Others counter that the plan is fair and unbiased.
Buyer beware
As a business owner, it is incumbent on you to check out all of your choices in health care plans. You owe it to your employees, but most of all, you owe it to yourself. You are assuming a large part of the cost of this coverage.
