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Can Long-Term Care Insurance Survive?

Why are long-term care insurance premiums rising faster than a speeding elevator? And what will become of the long-term care insurance marketplace? If you are interested in long-term care insurance, what’s going on and what may happen, read on.  If you have no interest in long-term insurance, then this is not the article you are looking for. (The next edition will take a closer look at the insurance consumer Bill of Rights).

Why Would Anyone Want Long-Term Care Insurance?

One of the largest projected expenses for the average American in retirement is medical expenses, with estimates approaching a total of $250,000.

Medicare and Medicare supplements provide coverage for medical expenses that are typically short-term or one-time, such as an annual physical, medical test or surgical procedure. Long-term care insurance provides coverage to pay the costs of service such as nursing home, in-home care and skilled nursing facilities that are not covered by Medicare or Medicare supplements. These costs are quite high—hundreds of dollars a day.  To see what the average cost of care in your area is, visit the Genworth Cost of Care page here.

The odds of needing some form of long term-care insurance can reach 50% or more, with an average claim period of two to three years (depending on the statistics you look at). According to the U.S. Department of Health and Human Services (HHS), by 2020, about 12 million Americans will require long-term care.

See Also: What Features of Long-Term Care Should You Focus On?

Long-term care insurance premiums will typically be in the thousands of dollars a year. However, just like with any other type of insurance, it is about the leverage of protecting against a risk—a simple financial calculation: Can you afford to pay for the risk in the event of a claim out of pocket and can you afford to pay the premiums? In terms of leverage, if you have a long-term care insurance policy with a total benefit pool of $250,000 and an annual premium of $5,000, the annual premium is 2% of the total benefit pool. If 2% sounds like good leverage to you, this policy makes sense.

The Big Question: Why Are Long-Term Care Insurance Premiums Rising? 

There are multiple layers to this questions, but the main underlying factor is that the first long-term care insurance policies offered by insurance companies had unlimited benefit periods on a type of coverage where they had minimal historical data. Think about it this way: If I offered you a bet on a football game this weekend with the provision that, if you win, I’ll pay you $100, and, if I win, you’ll pay me a $1 a month for the rest of my life. Now, that’s a great bet for me if my team consists of all-pros and your team consists of benchwarmers. Without knowing who is on your team, would you make this bet? There’s no need to answer; of course you wouldn’t.  Yet this is exactly the bet insurance companies made, just with much bigger numbers. And, unsurprisingly, this business model hasn’t been profitable for them.

There are some other major factors to consider, such as the prolonged historically low-interest-rate environment where insurance companies have not been able to make their historical investment returns. (This is something that no one could have foreseen.)

Another major factor is that insurance companies counted on a certain percentage of people lapsing (terminating) their policies at some point. Again, the insurance companies made this prediction without much historical data. And guess what? Policy owners actually liked and valued the coverage they purchased, and they have kept their long-term care insurance policies in force, despite some significant rate increases.

Premiums have had to be increased because, at the end of the day, it is in everyone’s best interest for insurance companies to be profitable. If an insurance company is not profitable, it will go out of business and will not be able to pay claims, which is definitely a problem.

Rate Increase Oversight and Perspective

Rates for in-force policies have been increased and will almost certainly face future increases; older policies still are priced lower than what a current policy would cost. Premium increases on long-term-care insurance policies have to be approved, in most states, by the state insurance commissioner. When faced with a rate increase, policyholders will need to consider whether their benefit mix makes sense and fits their budget. These are the “visible” rate increases.

If you have a long-term care insurance policy with a mutual insurance company where the premium is subsidized by dividends, you may not have noticed (or been informed) of a reduced dividend scale. When an insurance company reduces its dividend scale, it does not have to get approval from anyone or disclose that it has reduced its dividends. Reduced dividends mean a higher premium. This is a hidden rate increase.

As mentioned, policies issued today have significantly higher premiums than those issued in the past. Some rate increases are attributed to companies “catching up” on premiums to get closer to current premiums they hope are more accurate. The bottom line is that insurance companies are trying to bring the premiums on older policies into line with their current pricing on new products. The closer that pricing gets, the less likely it is there will be future premium increases. So, if you have an older policy (even if you’re faced with a significant premium increase), keep in mind you’ve gotten a discount on past premiums. While that’s not comforting in the face of a premium increase, it will help put things into perspective.

Insurance departments will approve premium increases so that they are sufficient to meet anticipated claims. Any increase granted must apply equally to all policy owners from the requested class of policies, and the carrier must keep the policy in force if the premium payments are made. Changes in age or health have no bearing on the contract premiums once issued; the policy may only be canceled if premiums are not paid. Nearly all existing long-term-care insurance policies have had one or more rate increases granted.

Please keep in mind that rates on other types of insurance also increase over the years, some slowly like auto insurance and homeowners insurance and some rapidly like health insurance.  Inflation affects everything. There are no nickel candy bars any more. This is all about the value of the coverage and the leverage of your premium to the total benefit pool.

Options When You Have A Premium Increase

When you have a premium increase, you should always start by reviewing your coverage and deciding whether you still need the current coverage or whether you can make changes. For example, because the average claim period is two to three years and there is a much longer benefit period, is the trade-off in premiums for the longer benefit period worth it? It is important to understand that, once a change is made, it cannot be undone, so be sure you are comfortable with any modifications.

The following are options when you have a premium increase:

  • Pay the increased premium.
  • Reduce the daily/monthly benefit amount.
  • Increase the waiting period.
  • Shorten the benefit period.
  • Change the inflation rider 
(e.g. go from compound to simple or reduce inflation percentage from 5% to 4%).
  • Change/remove other riders.
  • Terminate the policy.
  • If your policy has a non-forfeiture benefit that allows for a “paid-up reduced benefit,” consider this option: You’ll get at least some value for the premiums you’ve paid. But remember, once you accept the option, the policy will not be reinstated. Some states are now requiring all new policies to include this feature. (It’s relatively rare in older policies.)

New Long-Term Policy Designs (Hybrid/Combination Products)

With all the issues in the traditional long-term care insurance marketplace, there are very few companies selling individual long-term care insurance policies. Instead, insurance companies have come out with whole new types of products: hybrids and combinations. For instance, you can purchase a life insurance policy or an annuity with a long-term-care insurance rider. Other options are a life insurance policy or annuity that is combined with a long-term-care policy. (Rather than the long-term-care insurance being part of the rider, it is part of the policy.)

While, in theory, these sound like great ideas, they ignore some simple facts:

  • There may be no need for life insurance or an annuity, but you will be paying for the life insurance or annuity in addition to the long-term care insurance component.
  • Some require an up-front lump-sum premium payment.
  • These policies are complex and opaque. There are multiple variables to these policies that the insurance company can change and that will affect the performance of the policy—many of which do not have to be disclosed to the policy owner and do not show up anywhere. The more complex the product, the greater the chance that something won’t work properly.

Considering that insurance companies are still working on accurately pricing long-term-care insurance products and that universal life insurance policies are having issues (see: Will Your Life Insurance Policy Terminate Before You?), it is hard to imagine that combining two problematic products will magically work out.

The big selling point for these policies is that, with a traditional long-term-care insurance policy, the policy owner does not get anything back if there is no claim made. However, there is no expectation with any other type of insurance (except for life insurance) that there is a return if a claim does not occur, and most homeowners, for example, are happy when their house doesn’t burn down even though they don’t get any payout from their insurer.

Lessons Learned and a Positive Outlook For Long-Term Care Insurance?

There is no doubt of the importance of a thriving private sector long-term-care insurance marketplace. Public policy would seem to favor long-term-care insurance paid for by the private sector.

The Internal Revenue Service (IRS) is increasing the amount people may deduct from their tax returns this year when buying long-term-care insurance or paying monthly premiums. Check out the IRS page on long-term care Insurance premium deductibility here .

The Bipartisan Policy Center (BPC) released its first set of recommendations calling for increasing access to the private insurance market. BPC initiatives call for increasing access to the private insurance market, improving public programs such as Medicaid and pursuing a catastrophic insurance approach for individuals with significant long-term-care needs such as Alzheimer’s or a debilitating physical impairment. These proposals were developed by former U.S. Senate Majority Leader Tom Daschle along with Bill Frist, another former U.S. Senate majority leader, former U.S. Secretary of Health and Human Services Secretary and Wisconsin Gov. Tommy Thompson and Alice Rivlin, the former director of the Office of Management and Budget. They aim to address the needs of America’s seniors and specifically target middle- and lower-income individuals and families. Daschle said, “Today, families and caregivers are becoming impoverished by the financial demands of long-term care … Since there is no single, comprehensive solution to solve this unsustainable situation, our strategy calls for a combination of actions that could help ease the extraordinary financial burdens Americans are facing.”

If the BPC has its way, these retirement long-term-care policies would be sold on federal and state health insurance exchanges. The question is whether this can be accomplished. Part of the Affordable Care Act (ACA, aka Obamacare), the Community Living Assistance Services and Supports (CLASS) program established a national, voluntary insurance program for purchasing community living services and supports that is designed to expand options for people who become functionally disabled and require long-term help. Unfortunately, this program was abandoned because it wasn’t financially feasible.

History repeats itself

Back in the 1980s, insurance companies made similar poor product design decisions with individual disability income insurance. Unsurprisingly, claims experience was not great, and a number of companies left the marketplace. Is this sounding familiar?  The current individual disability insurance marketplace has returned with more sensible products, where the companies do full underwriting, offer benefits that are less than earnings and do not guarantee the premiums. A great read on this is: IDI Déjà Vu: Optimism For The LTCI Industry, by Xiaoge Flora Hu and Marc Glickman.

The long-term-care insurance industry is making similar changes to its products, which should buoy the marketplace. Products are being priced based on actual experience, policies are being fully underwritten and unlimited benefits are no longer available.

Smarter product design, better risk selection and a strong need should result in a solid long-term-care insurance marketplace. As America continues to age, there will be a stronger need for the coverage. It may take a few years, but there is a future for long-term-care insurance. The only real question is when.

Let me know what you think.

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13 Emerging Trends for Insurance in 2016

Where does the time go?  It seems as if we were just ringing in 2015, and now we’re well into 2016. As time goes by, life changes, and the insurance industry—sometimes at a glacial pace—does, indeed, change, as well. Here’s my outlook for 2016 on various insurance topics:

  1. Increased insurance literacy: Through initiatives like The Insurance Consumer Bill of Rights and increased resources, consumers and agents are both able to know their rights when it comes to insurance and can better manage their insurance portfolios.
  2. Interest rates: The federal funds target rate increase that was announced recently will have a yet-to-be determined impact on long-term interest rates. According to Fitch Ratings, further rate increases’ impact on credit fundamentals and the longer end of the yield curve has yet to be determined. Insurance companies are hoping for higher long-term rates as investment strategies are liability-driven. (Read more on the FitchRatings website here). Here is what this means: There will not necessarily be a positive impact for insurance policy-holders (at least in the near future). Insurance companies have, for a long period, been subsidizing guarantees on certain products or trying to minimize the impact of low interest rates on policy performance. In the interim, many insurance companies have changed their asset allocation strategies by mostly diversifying their portfolios beyond their traditional holdings—cash and investment-grade corporate bonds—by investing in illiquid assets to increase returns. The long-term impact on product pricing and features is unknown, and will depend on further increases in both short- and long-term interest rates and whether they continue to rise in predictable fashion or take an unexpected turn for which insurers are ill-prepared.
  3. Increased cost of insurance (COI) on universal life insurance policies: Several companies—including Voya Financial (formerly ING), AXA and Transamerica—are raising mortality costs on in-force universal life insurance policies. Some of the increases are substantial, but, so far, there has been an impact on a relatively small number of policyholders. That may change if we stay in a relatively low-interest-rate environment and more life insurance companies follow suit. Here is what this means: As companies have been subsidizing guaranteed interest rates (and dividend scales) that are higher than what the companies are currently (and have been) earning over the last few years, it is likely that this trend will continue.
  4. Increasing number of unexpected life insurance policy lapses and premium increases: For the most part, life insurance companies do not readily provide the impact of the two prior factors I listed when it regards cash value life insurance policies (whole life, universal life, indexed life, variable life, etc). In fact, this information is often hidden. And this information will soon be harder to get; Transamerica is moving to only provide in-force illustrations based on guarantees, rather than current projections. Here is what this means: It will become more challenging to see how a policy is performing in a current or projected environment. At some point, regulators or legislators will need to step in, but it may be too late. Monitor your policy, and download a free life insurance annual review guide from the Insurance Literacy Institute (here).
  5. Increased complexity: Insurance policies will continue to become more complex and will continue their movement away from being risk protection/leverage products to being complex financial products with a multitude of variables. This complexity is arising with products that combine long-term care insurance and life insurance (or annuities), with multiple riders on all lines of insurance coverage and with harder-to-define risks — even adding an indexed rider to a whole life policy (Guardian Life). Here is what this means: The more variables that are added to the mix, the greater the chance that there will be unexpected results and that these policies will be even more challenging to analyze.
  6. Pricing incentives: Life insurance and health insurance companies are offering discounts for employees who participate in wellness programs and for individuals who commit to tracking their activity through technology such as Fitbit. In auto insurance, there can be an increase in discounts for safe driving, low mileage, etc. Here is what this means: Insurance companies will continue to implement different technologies to provide more flexible pricing; the challenge will be in comparing policies. The best thing an insurance consumer can do is to increase her insurance literacy. Visit the resources section on our site to learn more.
  7. Health insurance and PPACA/Obamacare: The enrollment of individuals who were uninsured before the passage of Obamacare has been substantial and has resulted in significant changes, especially because everyone has the opportunity to get insurance—whether or not they have current health issues. And who, at some point, has not experienced a health issue? Here is what this means: Overall, PPACA is working, though it is clearly experiencing implementation issues, including the well-publicized technology snafus with enrollment through the federal exchange and the striking number of state insurance exchanges. And there will be continued challenges or efforts to overturn it in the House and the Senate. (The 62nd attempt to overturn PPACA was just rejected by President Obama.) The next election cycle may very well determine the permanency of PPACA. The efforts to overturn it are shameful and are a waste of time and money.
  8. Long-term care insurance: Rates for in-force policies have increased and will almost certainly face future increases—older policies are still priced lower than what a current policy would cost. This is because of many factors, including the prolonged low-interest-rate environment, lower-than-expected lapse ratios, higher-than-expected claims ratios and incredibly poor initial product designs (such as unlimited benefits on a product where there was minimal if any claims history). These are the “visible” rate increases. If you have a long-term care insurance policy with a mutual insurance company where the premium is subsidized by dividends, you may not have noticed or been informed of reduced dividends (a hidden rate increase). Here is what this means: Insurance companies, like any other business, need to be profitable to stay in business and to pay claims. In most states, increases in long-term care insurance premiums have to be approved by that state’s insurance commissioner. When faced with a rate increase, policyholders will need to consider if their benefit mix makes sense and fits within their budget. And, when faced with such a rate increase, there is the option to reduce the benefit period, reduce the benefit and oftentimes change the inflation rider or increase the waiting period. More companies are offering hybrid insurance policies, which I strongly recommend staying away from. If carriers cannot price the stand-alone product correctly, what leads us to believe they can price a combined product better?
  9. Sharing economy and services: These two are going to continue to pose challenges in the homeowners insurance and auto insurance marketplaces for the insurance companies and for policy owners. There is a question of when is there actually coverage in place and which policy it is under. There are some model regulations coming out from a few state insurance companies, however, they’re just getting started. Here is what this means: If you are using Uber, Lyft, Airbnb or a similar service on either side of the transaction, be sure to check your insurance policy to see when you are covered and what you are covered for. There are significant gaps in most current policies. Insurance companies have not caught up to the sharing economy, and it will take them some time to do so.
  10. Loyalty tax: Regulators are looking at banning auto and homeowners insurance companies from raising premiums for clients who maintain coverage with them for long periods. Here is what this means: Depending on your current auto and homeowners policies, you may see a reduction in premiums. It is recommended that, in any circumstance, you should review your coverage to ensure that it is competitive and meets your needs.
  11. Insurance fraud: This will continue, which increases premiums for the rest of us. The Coalition Against Insurance Fraud released its 2015 Hall of Shame (here). Insurance departments, multiple agencies and non-profits are investigating and taking action against those who commit elder financial abuse. Here is what this means: The more knowledgeable that consumers, professional agents and advisers become, the more we can protect our families and ourselves.
  12. Uncertain economic and regulatory conditions: Insurance companies are operating in an environment fraught with potential changes, such as in interest rates (discussed above); proposed tax code revisions; international regulators who are moving ahead with further development of Solvency II; and IFRS, NAIC and state insurance departments that are adjusting risk-based capital charges and will react to the first year of ORSA implementation. And then there is the Department of Labor’s evaluation of fiduciary responsibility rules that are expected to take effect this year. Here is what this means: There will be a myriad of potential outcomes, so be sure to continue to monitor your insurance policy portfolio and stay in touch with the Insurance Literacy Institute. Part of the DOL ruling would result in changes to the definition of “conflict of interest” and possibly compensation disclosure.
  13. Death master settlements: Multiple life insurance companies have reached settlements on this issue. Created by the Social Security Administration, the Death Master File database provides insurers with the names of deceased people with Social Security numbers. It is a useful tool for insurers to identify policyholders whose beneficiaries have not filed claims—most frequently because they were unaware the deceased had a policy naming them as a beneficiary. Until recently, most insurers only used the database to identify deceased annuity holders so they could stop making annuity payments, not to identify deceased policyholders so they can pay life insurance benefits. Life insurers that represent more than 73% of the market have agreed to reform their practices and search for deceased policyholders so they can pay benefits to their beneficiaries. A national investigation by state insurance commissioners led to life insurers returning more than $1 billion to beneficiaries nationwide. The National Association of Insurance Commissioners is currently drafting a model law  that would require all life insurers to use the Death Master File database to facilitate payment of benefits to their beneficiaries. To learn more, visit our resources section here. Here is what this means: Insurance companies will not be able to have their cake and eat it too.

What Can You Do?

The Insurance Consumer Bill of Rights directly addresses the issues discussed in this article.

Increase your insurance literacy by supporting the Insurance Literacy Institute and signing the Insurance Consumer Bill of Rights Petition. An updated and expanded version will be released shortly  that is designed to assist insurance policyholders, agents and third party advisers.

Sign the Insurance Consumer Bill of Rights Petition 

What’s on your mind for 2016? Let me know. And, if you have a tip to add to the coming Top 100 Insurance Tips, please share it with me.

The Dangers Lurking for Health Insurers

Heathcare is changing, creating opportunities but also dangers. Here is where healthcare is changing and why you should care in the insurance industry.

Providers. The physician you once saw and had a relationship with is now maybe a physician assistant or a nurse practitioner. Healthcare has turned care over to “mid-levels” and concentrated physician time on revenue-intense practice like surgeries or high relative-value-unit (RVU) patients such as elderly, as a reaction to the pressure on revenue and proliferation of data, The coding needs to be high for a patient to get physican attention, and the low coders, the healthy, are attended by mid-levels.

A mid-level is paid only a fraction of a physician. Makes sense? Expect care to reflect the nuance of matching. The result will be variation in diagnoses in health benefit insurance and workers’ compensation.

Isn’t there better data now? Yes, but who has time as a caregiver to be giving it thought? The ACA has driven more people to buy insurance, but that means less time per office interaction. Hospitals have bought physician practices, which now face new effectiveness expectations such as referral level and relative value unit per caregiver.

Caregivers are under enormous pressure to produce at your expense. Who can question “do no harm”?

Insurance industry. If you are a medical malpractice insurer, how does higher-deductible health insurance affect you? How does higher premium for health insurance mean you are at higher risk in offering medical malpractice? Can data be working against you?

The onus of care is now on the patient, and the patient is relying on engagement and education from anywhere it can be found. Google and the Mayo Clinic have teamed up to help by presenting search results verified by suitable medical communities, but the patient is on her own under the direction of a healthcare practice that is inundated with new patients and lots of data she can’t get to. And don’t forget that the attention is now being guided away from your physician. The standard of care has not changed, but the frequency of visits has lowered, and the time for every visit has decreased. Less care, too much data, too much patient expense and the same expectations of medical care. Not a picture of profit in medical malpractice. Maybe time to raise the price?

Workers’ compensation will get hit with increase in frequency and severity as care is slid to less dependable providers. You get what you pay for. One miss is worth a thousand hits in health. Providers are seeing patients too briefly to be always trusted, and the data…the providers are not even looking at the data. They are too busy plugging in data to appropriately spend effort on what it means.

General liability is a scarier risk as more patients mean more chaos and more visitors to the facilities. Who is watching security when the waiting room is packed up? Who is shoveling the lot? By the way, a patient fall is either medical malp-practice or general liability. Forget the $1,200 annual GL premium. Think $2,000.

Cyber liability is a huge concern as hackers get more sophisticated and the stakes in stolen health profile skyrocket.

Insurers can be venture capital. VC has figured out that there is a ton of money in health, but do they know much about health and what it does for insurers? Aetna’s CarePass was a great idea that needs to go on. Insurers should get on board with funding innovation. The VC money is slow. Technology is a VC specialty, yet health desperately needs people in play who know health. Physicians generally are not greatly interested in innovation. A tremendous opportunity is here for insurance companies to innovate with technology. Silicon Valley and insurance could team up and solve lots of issues. Now that it Google is out there, it is a great innovator in insurance. The opportunity is to bridge technology and insurance acumen. But VCs like to invest in people they know, like technology folks, so a gap indeed exists. Just saying.

Patients. High deductibles and high premiums for health insurance, combined with busy caregiving and new technology to grasp, mean the patient has a place at the healthcare table, finally, but no one to help much. It is up to the patient to take care of the patient. And your caregiver is very busy now that everyone has some kind of insurance. What a time to be finally given a place at the table.

How long of a visit does a patient get with his provider? Is it enough to rightly ascertain what is going on with a patient? Is surgery really the solution? Does chiropractic seem all that bad, Mr. Insurer? Does the caregiver get managed by how many referrals it proffers? Does the patient need to call the caregiver every time there is a stuffy head? Waiting rooms are filled, and time with the caregiver is down. Having a place at the table should mean more.

Innovators. Lots of techies are going after health care. Do they know healthcare? Not as much as you would hope. The right approach is to find innovators who get insurance and health and then parse technology. Not the other way around. Innovators look for faster capital and more knowledgeable partnership.

Make the data personalized and simple, as even caregivers cannot find time to analyze data. Health has a consumer face today, and lots of people looking for care guidance. The consumers want it simple and mobile. Anybody think insurance could be an available partnership candidate?

Healthcare vertical recombination is a major opportunity in insurance. Are you ready to lead?

Why to Self-Fund Health Benefits

The passage of the Affordable Care Act in 2010 continues to redefine the employer-sponsored healthcare market. Increased regulatory and fiduciary responsibilities, employer mandates and rising medical premiums have forced employers to evaluate all cost-effective strategies for providing health benefits to employees. One strategy, self-funding, remains an attractive alternative to the traditional fully insured and association-style health plans.

In a self-funded environment, the employer will assume the role of the insurer and agree to pay the medical claims incurred by the plan’s members and dependents. A good percentage of self-funded plans will also use reinsurance and captive risk tools to provide protection from both large individual claims and the plan’s collective utilization.

While self-funding has gained momentum as a result of healthcare reform, it is not a new concept. In 1999, a Kaiser Family Foundation (KFF) study reported that 44% of employer-sponsored healthcare was self-funded. That number has now reportedly grown to 61% in 2014.

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Why Is Everyone So Interested?

Health benefits continue to be one of the greatest expenses for employers. This fact, compounded with the continual rate increases (with little to no justification), leaves employers feeling stuck in an endless cycle. Some also may feel that their employees are a generally healthy group that is a good candidate to self-fund.

Many turn to self-funding because of:

  • Lower fixed costs-The majority of the expense is incurred in the payment of actual medical claims, increasing the margin for savings when the plan performs well.
  • Improved transparency-An increase in premiums is easier to swallow if the employer can get an accurate understanding of its claims experience. Self-funded health plans provide employers with a tremendous amount of data. Accurate claims data strengthens the group’s ability to effectively control spending on claims.
  • Control of the plan design-Self-funded health plans are in a better position to adjust benefits and control increased provider costs. Unlike fully insured products, a self-funded plan design can be structured to meet the specific needs of the group and not an insurer’s overall population.
  • Tax savings-Fully insured premiums continue to jump to accommodate new provisions as a result of the ACA. Self-funded plan sponsors avoid items like the new Health Insurance Industry Tax, which will increase from 2% to 5% in coming years.

With the increased interest comes new strategies and opportunities as the self-funding marketplace evolves. Self-funded plan sponsors are reaping the benefits of evolving provider network and cost containment strategies. Meanwhile, employers that have yet to make the transition see obstacles lessen because of changes in the reinsurance and captive markets.

What Does This Mean for Employer Groups?

Self-Funded Feasibility Studies Are a Must

There is a strong likelihood that every corporation or public entity with 1,000 employees or more has at least heard about self-funding. However, depending on the number of employees on your health plan, it is quite possible that you have not evaluated self-funding, at least in a thorough way.

A deeper look into the composition of employers participating shows us that group size typically has a direct correlation on whether a self-funded strategy is being used. According to the 2014 KFF study, the breakdown of corporations self-funding is:

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Historically, size has mattered. While all groups with more than 200 employees have a responsibility to evaluate the method as an alternative, those employer groups in the less-than-200 range are seeing more opportunity to make the transition. Lessening participation thresholds to lease competitive provider networks and new reinsurance and captive products are creating total-cost scenarios where the right employer can realize the advantages of self-funding. It can still be a challenge when certain market dynamics are present (i.e., lack of claims data, available provider network options, pending legislative actions, etc.), but more and more companies are finding success.

One More Step

The large insurance companies have noticed the changing market, as well, of course, and have introduced a number of bundled plans that look like self-funding. These products are typically entirely owned by one entity, like an insurance company or trust, and allow the employer to participate in a pre-determined portion of any surplus when the group experiences lower-than-expected claims. These products are attractive because they pull together under one brand all the component vendors of a self-funded health plan (i.e., claims administrator, network, reinsurance, etc.). These products can be a great first step for employers weary of self-funding through their own independent health plan. The products will allow them to gain insight into their claims performance while alleviating some of the additional work associated with the wholly owned approach.

For those groups already in these products, it may be time to evaluate taking that next step and realizing the benefits of a wholly owned approach. Reinsurance policies with specific advance and monthly aggregate accommodation can give these employers the ability to still limit their maximum exposure, lower their plan’s fixed costs and keep all of the savings when the plan performs well.

With the tools available today, any employer group in a packaged, shared funded or full ASO model plan is a candidate to complete the transition to a self-funded plan. While the packaged, branded approaches employed by some of the major insurance companies may work for a season, deconstructing the bundled product may be the next step in the employer’s long-term strategy.

Fine-Tuning Your Self-Funded Plan

There are many companies that have been enjoying the benefits of self-funding for years. As a result of the ACA, however, these employers have had to react to escalating medical costs, expensive specialty drugs and increased regulatory and fiduciary responsibilities.

For instance, self-funded health plans typically “lease” provider networks from a large insurance company. But, in 2010, the ACA removed lifetime and annual maximums from health plans, and the number of high-dollar claims has increased substantially. The networks provide discounts on fees, but the question is how important they are given the increasingly large charges they are being applied toward.

Self-funded health plans are adept in using different types of analytics both to measure historical data and to predict outcomes. This has empowered these health plans to fine tune their plans and integrate various cost-containment strategies.

Why Health Insurers Make People Ill

‘Tis the season for health insurance open enrollment, which can mean only one thing: My blood pressure is going up.

Health insurers talk a lot about how they’re my “wellness partner,” helping me “live a healthier life” and “empowering me to make good decisions.” But I find all they do is make me ill… sick with annoyance.

That’s perhaps best evidenced by the annual health insurance open enrollment process, when insurers put on a master class in exactly how not to treat your customers.

My open enrollment journey began with a letter from my insurer, indicating that my current health plan would no longer be available next year. However, the letter explained, the company had already selected a replacement plan that would best meet my needs.

Of course, the company neglected to tell me what that plan was. Perhaps the company felt that adding an element of mystery and suspense to the process would make it more exciting?

A few weeks later, the company graciously revealed its plan selection in a second notice. It picked a coverage option that was nearly twice as expensive as my current one – with a narrower provider network, to boot. It seemed like a selection that best met the company’s needs, instead of mine.

So off to the Internet I went to research my alternatives. That alone was an adventure, given how many insurers’ health plan websites appear to have been designed by crazed, blind hermits.

My personal favorite was one major insurer’s site, where about half the links to health plan details yielded the dreaded “404 Web Page Unavailable” error. I guess the company really wasn’t interested in getting my business (or anyone else’s).

After evaluating other offerings, it was time to figure out what my options were with my current insurer. Naturally, the company’s online plan descriptions triggered more questions than they answered – which meant I’d have to contact the insurer’s 800-line service center (also known as Dante’s Ninth Circle of Hell).

All I wanted was to speak with someone who could help me. But that was clearly setting the bar too high.

Once I navigated the labyrinth that was the 800-line menu, I was subjected to a series of pre-recorded messages, including one that felt less like a call center greeting and more like an oral history of the Affordable Care Act.

Then there was the 20-minute wait until a representative was available, with the on-hold music periodically interrupted by an ironic recorded assurance that the company “values my time.”

The company valued my time so much that it made sure to consume a lot of it. That first call lasted more than two hours and included 10 transfers, because nobody seemed to be the “right person” to help me. You’d think I was asking about some arcane plan feature, but all I had were some straightforward questions comparing networks and benefits across two of the company’s plans.

Each service representative I spoke with began the conversation using the same scripted phrase: “What would you like to accomplish today on this call?”

“I’d like to not get transferred,” was the reply I started using about an hour into the odyssey. “That’s my goal on this call.” The vast majority of the people I spoke with were unable to satisfy even that simple request.

Oftentimes, I found I knew more about these plans than the enrollment representatives themselves. I even resorted to walking one of them, step by step, through the company’s own website materials, when the rep insisted the plan I was considering had no out-of-network coverage. (It did, and the rep finally concurred.)

Even after this first marathon call ended, I was compelled to call again… and again and again.

In some cases, it was to follow-up on information that enrollment representatives had promised to send me but never did.

In other cases, it was just to ask the exact same questions of another person, because I had absolutely no confidence in the responses I was getting. I would pose the same question to three representatives and get three different answers. That’s how my insurer empowers me to make a good decision?

My experience is not uncommon; health insurers routinely bring up the rear in cross-industry customer satisfaction rankings. It raises the question, though: How much unnecessary expense are these companies incurring as a result of all this incompetence?

If health insurers simplified their products a bit, if they made their information materials a little clearer, if they trained and equipped their staff better – how much consumer confusion would they mitigate? How many incoming calls, e-mails and tirades would they preempt? How much operational savings could they pass on in the form of more affordable coverage?

In a health insurance marketplace that’s becoming increasingly consumer-directed, many insurers have taken to the airwaves to highlight how they enrich our lives and improve our well-being.

But you can’t advertise your way to a good customer experience. If health insurers are serious about improving my well-being, they can start by creating an open enrollment process that’s more satisfying than it is sickening.

This article first appeared at LifeHealthPro.