1. Health Plan Overview & Updates
City of Sebastian
City Council Meeting
Monday, August 20, 2012
Presented by:
Christian Bergstrom, Director – Analytical Services

2. Background:
Claims Experience &
Plan Changes

3. Total Physician Claims
Claims Experience
Date
MONTHLY PREMIUM
Total Hospital Claims
Total Physician Claims
Other
Pharmacy
Capitation
TOTAL CLAIMS
Loss Ratio
Total
Members
October-10
$93,241.72
$48,204.75
$22,272.03
$6,345.03
$28,503.01
$128.71
$105,453.53
113%
November-10
$89,723.92
$142,227.14
$27,439.22
$3,518.09
$16,719.27
$127.49
$190,031.21
212%
December-10
$89,713.92
$61,367.14
$36,922.12
$5,223.52
$17,088.94
$128.10
$120,729.82
135%
January-11
$39,857.47
$18,466.44
$11,821.58
$19,632.12
$123.22
$89,900.83
100%
February-11
$89,222.81
$60,085.13
$21,255.17
$5,256.73
$9,157.53
$125.05
$95,879.61
107%
March-11
$90,520.69
$37,711.96
$17,357.33
$16,624.98
$17,770.77
$125.66
$89,590.70
99%
April-11
$86,363.98
$90,305.24
$18,213.99
-$5,956.38
$16,774.42
$123.83
$119,461.10
138%
May-11
$88,869.53
$65,822.89
$27,049.95
$7,078.78
$15,312.38
$124.44
$115,388.44
130%
June-11
$90,841.41
$212,309.30
$28,323.60
$31,822.68
$15,437.42
$130.54
$288,023.54
317%
July-11
$90,781.28
$106,079.31
$38,329.36
$8,030.42
$16,111.70
$126.27
$168,677.06
186%
August-11
$90,124.07
$152,633.34
$36,744.79
$11,407.43
$15,890.44
$129.93
$216,805.93
241%
September-11
$91,110.84
$218,835.00
$19,288.30
$22,873.99
$15,069.46
$276,195.46
303%
117
113
112
110
111
Total
$1,080,238.09
$1,235,438.67
$311,662.30
$124,046.85
$203,467.46
$1,521.95
$1,876,137.23
173.7%
1350

4. Total Physician Claims
Claims Experience
Date
MONTHLY PREMIUM
Total Hospital Claims
Total Physician Claims
Other
Pharmacy
Capitation
TOTAL CLAIMS
Loss Ratio
Total
Members
October-11
$91,231.35
$53,182.89
$12,580.63
$9,626.98
$7,590.75
$130.54
$83,111.79
91%
November-11
$90,229.13
$200,709.93
$9,745.54
$829.21
$911.84
-$12.81
$212,183.71
235%
December-11
$84,580.45
$64,204.01
$11,945.86
$4,114.98
$2,014.87
$0.00
$82,279.72
97%
January-12
$75,782.19
$18,069.72
$11,539.30
$1,717.62
$596.53
$31,923.17
42%
February-12
$81,465.53
$22,815.71
$7,193.47
$6,611.32
$3,544.29
$40,164.79
49%
March-12
$33,366.56
$5,795.53
$9,826.44
$3,339.44
$52,327.97
64%
April-12
$78,456.92
$35,590.29
$11,015.33
$12,545.74
$5,645.05
$64,796.41
83%
110
106
104
103
101 99
Total
$583,211.10
$427,939.11
$69,815.66
$45,272.29
$23,642.77
$117.73
$566,787.56
97.2%
733
Rolling 12 Months
$1,034,938.23
$1,183,618.95
$219,551.66
$126,485.59
$101,464.17
$757.62
$1,631,877.99
157.7%
1291

5. Claims Per Employee per Month

6. Catastrophic Claims (12-months)
4 Individuals with billed claims > $50,000
$3,760, in total billed claims

7. Medical / Dental Renewal
Medical Insurance:
Initial Florida Blue Renewal:
14.8% Overall Increase or $140, Annual Increase
Negotiated Florida Blue Renewal
10.4% Overall Increase or $98, Annual Increase
Savings of $41, from initial renewal
Dental Insurance:
Florida Combined Life Renewal:
10% Overall Increase or $7, Annual Increase

8. Life / LTD / Vision Renewal
Life and AD&D Insurance:
Florida Combined Life Renewal:
0% Overall Increase
Long Term Disability Insurance:
Vision Insurance:
Florida Blue (Davis Vision) Renewal:

9. Request for Proposal
A RFP was released to the market on May 18th, 2012 for all lines of coverage
Results:
Medical: All carriers Declined to Quote due to large claimants, limited network, and/or uncompetitive rates
Dental: 7 proposals
Vision: 5 proposals
Life / AD&D: 9 proposals
Long Term Disability: 9 proposals

10. Renewal Recommendation
Medical Insurance:
Remain with Florida Blue but transition to an alternative HDHP
8.1% Overall Decrease in premium or $76, annual savings from current
Single / Family Out of Pocket Maximum increases by $1,500 / $3,000 from current plan
In Network Coinsurance Level increases from 10% to 20%
Health Reimbursement Account:
Use savings to increase employee’s Health Reimbursement Account amounts to 100% of Single / Family Deductible (Currently 50%).
Total overall increase (including higher HRA amount) is 3%
(Total overall increase renewing current plan with same HRA amounts is 9.4%)

11. Renewal Recommendation
Dental Insurance:
Transition dental plan from Florida Combined Life to Assurant
9.5% Overall Decrease in premium or $6,793 annual savings from current
Assurant’s proposed benefits match current FCL dental plan
Vision Insurance:
Remain with Florida Blue’s (Davis Vision) vision plan
0% increase in rates

12. Renewal Recommendation
Life and Long Term Disability Insurance:
Transition Life / LTD plans from Florida Combined Life to The Hartford
31% Overall Decrease in premium or $11, annual savings from current
Plan Changes:
Life: Increased Accelerated Death Benefit
LTD: Increased Own Occupation Period of 12 Months to 24 Months

13. $10 / $30 / $50 after deductible
Benefit Changes:
Benefit
HRA Plan / 05181
HRA Plan / 05191
Health Reimbursement Account
$750 Single / $1,500 Family
$1,500 Single / $3,000 Family
Calendar Year Deductible(CYD)
(In-Network / Out-of-Network)
Single: $1,500 / $3,000
Family: $3,000 / $6,000
Out of Pocket Maximum (OOPM)
Single: $3,000 / $6,000
Family: $6,000 / $12,000
Single: $4,500 / $9,000
Family: $9,000 / $18,000
Coinsurance- In Network
Member pays 10%
Member pays 20%
Primary Care Physician Office Visit
10% after deductible
20% after deductible
Specialist Office Visit
Maternity Initial Visit
Emergency Room Visit
Urgent Care Facility
Inpatient Hospital (Option 1 & 2)
20% / 25% after deductible
Outpatient Hospital (Option 1 & 2)
Ambulatory Surgical Center
Advanced Imaging (MRI, PET, CT)
Prescription Drug
$10 / $30 / $50 after deductible
Please note that Preventative Care is not subject to deductible or coinsurance. Employees receive this coverage for free.

14. Health Reimbursement Account
How does the HRA work?
Sebastian contributes $1,500 annually to each employee who participates in the health insurance plan. In addition, if you cover your spouse and/or child(ren), Sebastian will contribute an additional $1,500 annually for a maximum of $3,000 annually.
These funds remain with Sebastian until they are actually claimed for reimbursement.
Employees will receive a debit card to pay for medical plan expenses. If a provider does not accept a debit card, the user will pay the cost for the incurred expense at the time of service and then claim reimbursement from the plan administrator. This reimbursement is not subject to income tax.
Even employees that utilize the debit card may have to submit a claim form along with the Explanation of Benefits from BlueCross BlueShield of Florida to validate expenses.
All claims must be filed within 90 days after the end of the plan year in order to claim reimbursement. Any unclaimed funds at the end of the year will remain with Sebastian.
Employees that participate in the employee funded flexible spending account (FSA) will utilize those funds prior to utilizing the HRA.

15. Health Reimbursement Account BCBSFL Sample Discounted Rates
How does the HRA work (Example 1 – Employee Coverage)
Out of Pocket Expenses
BCBSFL Sample Discounted Rates
1 Primary Care Office Visit ($40/visit)
$40
1 Specialist Office Visit ($250/visit)
$250
1 Preferred Rx per month (12 x $40/month)
$480
Total Cost
$770
Annual HRA Account Contribution
$1,500
HRA Reimbursement
Member Out of Pocket Expense $0
Remaining HRA Balance
$730

16. Health Reimbursement Account BCBSFL Sample Discounted Rates
How does the HRA work (Example 2 – Family Coverage)
Out of Pocket Expenses
BCBSFL Sample Discounted Rates
6 Primary Care Office Visits ($40/visit)
$240
2 Specialist Office Visits ($250/visit)
$500
3 Urgent Care Visits ($150/visit)
$450
3 Generic Rx per month (12 x $10/month)
$360
Total Cost
$1,550
Annual HRA Account Contribution
$3,000
HRA Reimbursement
Member Out of Pocket Expense $0
Remaining HRA Balance
$1,450

17. Flexible Spending Account
How does the FSA work?
Employees may elect to contribute a portion of before-tax income each pay period
Tax-free money is used to reimburse employees for eligible expenses incurred during the year for themselves & qualified dependents
Two types of FSA’s will be offered:
Health Care Reimbursement Account
Dependent Care Reimbursement Account

18. Flexible Spending Account
How does the FSA work? (Health Care Reimbursement Account)
This benefit allows an employee to set aside money from each paycheck to cover services not covered by their medical or dental plan (i.e. deductibles, coinsurance, orthodontia, prescriptions, dental, glasses) up to a maximum of $5,000. This can be applied to unreimbursed medical expenses incurred by the employee, their spouse, and children, regardless of whether or not they are covered under the employee’s health insurance plan.

19. Flexible Spending Account
How does the FSA work? (Dependent Care Reimbursement Account)
This benefit allows an employee to set aside a month from each paycheck for child-care expenses (i.e. after-school care, day care, camp fees) up to a maximum of $5,000 filing single or $2,500 filing jointly.

20. Flexible Spending Account
How does the FSA work?
All selections are made for an entire year and no changes can be made during the plan year except for qualifying events.
At the end of the plan year if any funds are unclaimed, they will be forfeited and returned to the City (“use it or lose it”)
Example
Without FSA Account
With the FSA Account
Gross Earnings $2,000
FICA, Federal Taxes $500
Insurance Premium $100
Health & Day Care Expenses $300
Adjusted Gross Earnings $1,600
FICA & Federal Taxes $400
Net Earnings $1,100
Net Earnings $1,200

21. Health Care Reform Considerations for 2012 – 2013
Medical Loss Ration (MLR) Rebate
Aggregate premium by market by state
Rebate not due to Sebastian
Women’s Wellness Initiative
Summary of Benefits & Coverage (SBC)
FSA limit reduced to $2,500
Does not apply for plan years that begin before 1/1/2013.

22. Question & Answer