Design & Strategy Considerations For Offering Employee Benefits Berkshire Associates Incorporated has a common goal in offering

benefits to their employees. However, difficult market conditions caused by a number of factors have made offering these benefits nearly impossible from a financial standpoint. Lisa Stone, the director of HR at Berkshire, has the duty of implementing a competitive, cost-effective benefits plan and shares some of her insight on the philosophy of offering benefits to their employees. Ms. Stone has identified their ideology behind offering benefits by stating that BAI offers employee benefits to attract new valuable talent and retain old employees who understand their system but mostly to create a culture at work where employees feel more valued than a traditional business setting which can boost morale and productivity. This philosophy in offering benefits is a noble one but Ms. Stone also states that BAI must also be cognizant of the increasing costs of not only offering these benefits to employees, but offering them in the climate that healthcare is in right now. BAI has been able to do this by adding new, more flexible work-life benefits; in particular their telecommuting and tuition reimbursement benefits. Their telecommuting benefit gives employees the choice to work from home if they supply specific levels of productivity. Employees love this benefit since they can avoid traveling expenses incurred by coming into work. Tuition reimbursement has been a big benefit for BAI since their demographics are majority female, trending to a younger age group. Their young population at work naturally leaves more potential candidates to be in an undergraduate or graduate position. So the issue at hand with the design considerations of offering benefits next year will be to offer the most competitive benefit plan while keeping the increase in costs to a minimum. This obstacle is even more difficult considering the size of Berkshire Associates. Berkshire Associates has 85 employees that are eligible for benefits and about 40 dependants on the plan. With participation in healthcare benefits slightly over 70%, Berkshire must consider their size and what reform has done for their classified size of business. Berkshire Associates Inc. (BAI) began their planning process by, creating a basic benefit [plan] to be competitive in the HR consulting industry, says Lisa Stone, BAIs HR consultant and founder. The basic benefit options were health insurance, dental insurance, 401(k), life insurance and disability. Since BAI is a small company of 85 employees, it uses Third Party Administrators (TPAs) regarding, anything with external vendor[s], she said. BAI
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benefits from the administrative relief from TPA outsourcing and the cost and time associated with administrating the plan. Strategically, BAI join forces with brokers for dental, life and disability insurances, to see which is most rich. Stone describes much of the benefit design to be dictated by the staffing industry and competition therein. BAI strives to meet employee needs by research and cooperation. Given BAIs corporate culture, employees often volunteer their feedback regarding benefits. In particular, employees commonly request products from AFLAC, the supplemental benefit provider. Tellingly, AFLAC appeals to BAI employees because, [its] policies are slightly different than regular life and disability because of additional, specific coverage and they have a lump sum dollar amount indemnification based on the situation. BAI will focus on mitigating the inflation of prices since reversing the trend is impossible while offering the same or even more comprehensive benefits. Since there seems to be ever increasing costs associated with offering healthcare coverage, Berkshire Associates will need to reduce costs in offering these and other benefits. However, BAI cannot just cut benefits at all costs in an attempt to reduce premium price. If they want to remain competitive, BAI must always offer at least the same benefits as its competitors. Lisa described some of the benefits as set in stone meaning that the offering of these benefits will probably never change since the cost and importance of these benefits wont change either. Some examples of these benefits are life and disability insurance, and retirement benefits such as the 401(k) plan. There is a lot of room in the Berkshire Associates benefit plan to reduce cost without reducing the comprehensiveness of their program in place. The Maryland Small Group Reform helps Berkshire Associates in the meantime before the full changes implemented in health reform take place in 2014. A significant consideration in the design and strategy in offering employee benefits will have to be the impact of the new Maryland small group reform. The Maryland small group reform law encompasses a few provisions to ensure the protection of the small group market place through protecting price inflation and changing criteria that deem candidates eligible for coverage. These provisions include guaranteed issuance, modified community ratings and no pre-existing condition limitations. This new mandate can help or hurt a small groups given the course of action taken. This reform was created to protect the small group market place as employee participation has dropped significantly since 1999. According to the Maryland
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Healthcare Commission, employer participation had declined by 9% before the reform over a ten year period. More notably, employee participation had declined over 14% before the reform1. These numbers indicate how needed the reform was and according to Lisa Stone the reform has actually enriched our benefits and helped to keep the price inflation manageable. Healthcare is the primary cost driver in most benefit plans. It is extremely important that BAI work with brokers to find cost-effective alternatives to their current options as increasing costs wont be protected by the Maryland small group reform beyond 2013. Many employers are opting for consumer directed health plans2 (CDHPs) to reduce the cost that they are responsible for. CDHPs offer coverage with a high deductable (>$2,400) leaving the employee with the burden of more out-of-pocket expenses and also forces the consumer/employee to take more responsibility in the use of their healthcare benefits. CDHPs are often coupled with an HRA, FSA or HSA. These types of plans are very cost-effective but some employees opt out for specific reasons such as domestic partnerships. Domestic partnerships do not receive tax favorability since they dont meet the requirements for them by law. Some employees opt out for PPO coverage because they have children or a specific preference with who they receive their healthcare treatment from. So other options must remain in the program to encompass these specific individuals but some method of steering must take place to get more individuals to take the CDHP option. Even though the Maryland small group reform law is good for the time being it is important that BAI keep in mind alterations they will need to make in order to comply with new federal regulations brought on by health reform. When asked what benefit the employees at BAI value the most and why, Lisa explained that the AFFLAC voluntary benefit program was the most requested inclusion in the benefits program since she has been with BAI. The AFFLAC voluntary benefit program is great for the current and future designs of the benefit program. Lisa stated that employees were so into the AFFLAC program because it reduced the overall cost of healthcare for everyone by slimming down what had originally been offered and provided specific options that tailored to individuals specific needs. This ideology is great for a benefits program and might be where benefits ends up ultimately; with a plan that provides the bare minimum and many voluntary options that tailor
1

http://mhcc.maryland.gov/smallgroup/sgm_reform.pdf
A Shift Towards Smaller Health Insurance Networks. Los Angeles Times

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the plan to an employees specific needs, whether it be for dependents or a spouse. Employees at BAI are not opposed to voluntary benefits if it reduces the cost of other benefits or even eliminates the ones they never utilize. Every person has specific and general needs, a healthcare plan should target the general needs and a voluntary plan should be a decision that employees make based on what they deem necessary enough to purchase. Controlling the problem of marginal benefit far exceeding marginal cost in the healthcare market is made possible through voluntary benefits and can severely reduce the cost of a benefit plan if employees are willing to participate. In conclusion BAI should consider some slight changes in the design of the overall offering of the employee benefit plan. BAI is a small employer so the pressures that are affecting the market place are especially stressful for them. Larger companies can opt out and provide selffunded benefits. Since BAI is so small they dont have the capital to take on this project. Since BAI is so small they must rely on brokers to help draft options for the plan and insurance carriers to carry out third party administration. BAI should remain aware that brokers receive commission for the amount of coverage in a plan. This can cause an issue in letting your broker draft the plan for you. They may add in unnecessary coverage that no one at Berkshire utilizes. Lisa should get much more involved in creating the healthcare options and the limits under other policies to reduce moral hazard and price. Lastly, many steps need to be taken in consideration for the future. The Maryland small group reform initially took place in 2009 and has helped keep price inflation down, but with new regulatory compliances that will arise through PPACA and any new organization set to aid in healthcare reform, BAI can face a very difficult compliance issue.

Considerations for Health Care Benefits Introduction Berkshire Associates Incorporated strives to offer is a smaller employer, and their status as such predetermines many of their plan design decisions. The loss experience of their 85 employees has more variance than that of a larger employer and makes the employer actuarially incredible for retrospective and prospective. State legislation and PPACA has a positive effect on
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the benefits offered while some aspects of PPACA could have a negative effect on health care options in years to come. BAIs relatively small workforce indirectly affects its choice in Third Party Administrators, because TPAs are chosen based on plan needs. Further, legislation affects the value that a small Maryland TPA can get from a TPA or ASO. Communication of HealthCare Benefits Communicating exactly all the benefits included in the plan clearly to all employees can help them understand the true value of their plan. BAI should arrange a health care evaluation & utilization program. Make it "mandatory" or so essential/ingrained in workforce that a vast majority of plan participants attend. BAI can include a segment on child care: many employees pay attention when children are mentioned, even single workers have children as extended family. Have them stress the underuse of vaccination, since they are covered under preventive care, and the overuse of antibiotics that creates antibiotic-resistant bacteria. Address the rumor of the vaccinate-induced autism in children and dispel it. Children are a touchy subject and should cue employees in to the seriousness of healthcare. For older workers, BAI should have a panel or guest speaker(s) note the Medicare coverage of, "beta-blocker treatment" for heart attacks and eye-exams for diabetics. Both the aforementioned healthcare services have proven to be effective in studies from 2010. Additionally, the most elderly of the workers and former employees should be informed of proper fall-prevention care and management of urinary incontinence. Inform current older workers at the meeting and former employees through a letter. There are several special topics that should be included as medical advice to all. Encourage the medical experts to warn the workforce of the dangers of poor diet and a sedentary lifestyle, especially regarding chronic diseases like diabetes, heart disease and high blood pressure/hypertension. Have a panel of people from the medical field (dr. nurses, medical students, practitioners from medical associations and plan administrators). Have the panel stress particulars of health care utilization. Also have them stress the continued use of their medications for chronic illnesses. "Patients with well-managed diabetes can gain five or more years of life". They should speak on effective care and the dangers and possibilities of costly and ineffective

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treatments. Be sure to have the broker present to communicate exactly how to effectively use the medical advice provided. Having the broker verbally inform employees will clarify any issues. Communication of simpler procedures offered through the plan needs to improve. All medical option on the plan offer compressed testing where employees can receive a multitude of tests in one-to-three days. This is especially useful for productivity because it can prevent disease advancements and minimized the time away from work to receive the screenings. (Chlamydia, colorectal cancer, etc) These parts of the plan are considered underutilized by Lisa and they can add great value to the employees if they were better communicated. Administrative Outsourcing Moreover, Third Party Administrator selection is crucial in a way that is specific to smaller employer. A smaller employer like Berkshire Associates may want to compensate for its small size as a company by using household name providers as Administrative Services Only (ASO) for brand recognition and sense of security. Even still, State legislation, like Marylands Small Employer Health Care Reform, and federal regulations (PPACA) can take the employer out of the off-the-shelf market for insurance productand so much so that national ASOs and TPAs lose an appetite for that service. Conversely, many smaller TPAs offer flexibility in plan design and more personal service, which smaller employers want. Normally, small companies benefit from data mining to track the effectiveness of plan design changes but Maryland Small Employer Reform, does not allow the insurer or TPA to track claims data nor use claims data to effect premium. BAI has decided to use, regional network that serves Maryland, District of Colombia and Virginia for health insurance and claims administration whereas it chose, a national network dental, life insurance, disability insurance and [management of the] 401(k). The company used a regional vendor and administrator anticipating plan participants utilizing more in-network health services if provided locally. Otherwise, dental and disability are secured largely through volunteer benefits via AFLAC and is not the BAIs as much a concern for BAI. Life and 401(k) benefits are not as frequently used or personal services as health care and do not suffer from not being offered locally. Strategic Waiting Period

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BAI manages its financial risk with its various waiting period for certain benefits. Namely, there is on new hires only await, the first of the month after the date of hire in order to receive coverage for any of the base health insurance or dental insurance, and the 401(k) benefit begins the first day of employment since, they are important to employees says Stone. On the other hand, access to FSAs, life insurance and disability is deferred 90 days from employment because, they pose a greater financial risk to the employer. HR generalists Stone identifies admitted adverse selection concerns in that, [medical] FSA amounts as elected [at the beginning of the plan year and] before the salary deduction available Stone notes. So to manage the risk brought on by asymmetric information regarding a terminally ill or previously injured workers attempting to finagle their way into employment for the sake of coverage. Given the shrewdness of BAIs HR employees, a lethal combination could arise: BAI wisely offers flexible spending options for employee attraction and retention, yet BAIs labor market are mostly sophisticated health care consumers who are very capable of adversely taking the job for any vulnerabilities in plan design. In particular, the BlueChoice Open Access Opt-out Plan has no waiting period and provides delivery services and facilities for maternity at a no charge or deductible. Relay for Life and other Exercise Incentives Paid participation in "relay for life" or equivalent for-charity marathon could be a multiple-purpose effect. In addition, offering a prize to the winner of the competition or a winner chosen by lot could be a great incentive for participation in the marathon or event. It demands exercise; therefore the event will imply weight control and individual training. Studies show that a sedentary lifestyle and poor diet cause chronic diseases like diabetes; participation in these events can help employees arrive at their own conclusion as to their health status. Additionally, such an event will encourage employees to abstain from harmful substance abuse like tobacco, drugs and alcohol. Participation will foster camaraderie from the challenge and off-site bonding. As well this could boost morale by allowing employees to get paid time to get out of the office. [Participation in volunteerism benefit]. Ultimately, many employees may collectively value their health. Hopefully participation in the event will be increased from the panels' advisory about the woes of a "sedentary lifestyle". Be sure to stress the charitable cause as a focus and something in which they should participate. Plan this volunteer effort at a convenience time and advertise the event well in
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advance. If given in advance notice you can have preliminary physical examinations as a "safety precaution" but as a health care preventive measure as well. Include screenings for chronic diseases like the HbA1c and LDL-C screenings for diabetes. Consider allowing family members of employees to attend as many will be the same dependents covered under BAI's health benefit(s). Lastly, be sure to be very accommodating in the execution of the marathon. Provide transportation, water, fruits, energy bars, towels and the like. Collaborate closely with your broker regarding the communication and implementation of this event. Issues and Considerations in Compliance and Regulations The overall aim of the Patient Protection and Affordable Care Act (PPACA) is to make health care for reasonable in the insurance market and to provide coverage to the millions of uninsured Americans47 million as of 2006. Drug purchasing, necessary benefits, IRS reporting and additional tax-favoring are among the changes to become effective between 2011 and 2014. There are certain changes to PPACA that will go into effect in the 2011-2012 fiscal year. Specifically, over-the-counter (OTC) drugs not be considered IRS tax-exempt with a FSA, HRA or HSA and will not be tax deductible either. In other words, plan participants will need to get a prescription for OTC drugs in order for them to be covered. An industry trend is that plan participants with dependent and medical FSAs (Section 125 pre-tax salary reductions) and HRAs wait until nearly the end of the plan year to utilize their money on prescription products before the money is remitted to the employer. Note that many health care providers get frustrated from the hassle of the prescription rush from the multitude of health care plan participants from various plans that rush to spend pre-tax dollars when mot plans have similar yearly conclusions. Consider having periodic meetings with new hires and HRA and FSA participants specifically as to monitor this spending wisely. During the 2011-2012 fiscal year, employers will be expected to excise non-salary income into line 17 of the W-2 tax income forms. It behooves BAI to comply to W-2 prior to it being necessary so that the employer will be accustomed to the change rather then rushed to comply and possible make errors at the employers risk.. There is a very good chance that your plan options will become taxable at some point and that federal regulators are seeking benefit
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compensation transparency in order to later impose a tax. Be sure to have a conversation with your broker about the Cadillac Plan Tax of potentially 40% regarding rich plans and ways to bend the cost curve as a proactive measure (See Cost Containment Strategies below). The federal regulation in question does a great deal to mandate essential health benefits (EHB) into insurance products. According to section 1302 of PPACA, essential benefits include at least ten categories of medically necessary benefits: (1) ambulatory patient services (2) emergency services (3) hospitalization (4) maternity and newborn care (5) mental health and substance use disorder services (5) prescription drugs (6) rehabilitative and facilitative services (like substance abuse services) and devices (7) laboratory services (8) preventive and wellness services (9) chronic disease management services and (10) pediatric services, including oral and vision care. There will be no lifetime limit for the aforementioned health services types under PPACA starting January 1st, 2014. There will be annual limits in place as well so BAI should consider that as well when designing their new benefit plan. In reference to PPACA among other new legislations, Lisa Stone speaks to how benefits have been enriched. At the same time, BAI must be aware of premium inflation from such mandated service coverage. Much to your advantage, PPACA thwarts some of the controversial insurance practices. PPACA expressly outlaws preexisting-condition exclusions (PCEs) and the rescission of enrollee coverage. The rescission provision is excluded in the event of fraud and intentional misrepresentation of a material fact to the insurer. By extension, a material fact is any fact that relates to whether the insurer would have written the coverage and whether the premium would be affected. In other words, be sure to be straightforward, honest, specific and in good faith when communicating with your insurer or they reserve the right to rescind coverage. Even more, be sure not to answer your insurers question. As well, dependent coverage has been extended to children up to age 26 regardless of residence, income dependence, marital status or education status. This broadens the definition automatically if you choose to offer dependent coverage in too because you do not have to cover dependents as defined. Furthermore, there will be restrictions on the use of HSAs and FSAs in the near future. The HSA excise tax increases from 10% to 20%. Otherwise there is a $2,500 cap on medical FSA annual contributions that will be effective in 2013. Finally, your fully insured plans will be held to the same regulatory standard (IRS code 105(h)) regarding discrimination testing and resulting favorable tax treatment
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eligibility. Favoring of highly compensated employees (top 25% salaries employees and top 10% of stockholder for publicly owned companies) in terms of eligibility and actual distribution of benefits will lose tax-exemption. Formerly only self-insured plans had to worry about such compliance. The controversial matters should be discussed in further detail with a knowledgeable broker or consultant. PPACA will directly affect small businesses like BAI in a number of ways. In particular, some small businesses will qualify for tax credits in order to avert cost of employer contributions. Starting in 2010, tax credits could be applied for up to 35% of employer premium contributions. Further, tax Exchanges will become available to small employers to avert up to 50% of taxes. Discussion need to take place with your broker regarding sustainable eligibility of small employer/business status as BAI continues to grow.

Design Considerations for other Non-Retirement Benefits Berkshire Associates Incorporated has relatively young demographics. Benefits like tuition reimbursement and telecommunicating have really been a success in attracting new younger talent. Tuition reimbursement gives employees a chance to go back to school and increase their skill and productivity. BAI and an employee can gain significantly from this arrangement. BAI offers $2,500 for undergraduates seeking a degree and $4,000 for graduates. Berkshire should consider slightly increasing their contribution to this benefit to give employees an incentive to become more valuable with a masters or undergraduate degree. With a more educated workforce, Berkshire can take advantage of their telecommunicating benefit. More qualified, skillful workers would mean there would be less need for administrative pressure. Since BAI does contracted third party administration, the location in which these services are completed is irrelevant. BAIs telecommunicating benefit has also been a hit with employees. Many employees opt out of coming into the traditional place of and instead complete all work from their home. There are a few requirements like availability for meetings, amounts of work that need to be completed and delivered each day, and a certain amount of hours in a row an employee must be near a phone for contact purposes. Employees have willingly accepted these added responsibilities in return for the chance to work when they want to, without having to
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incur the costs of commuting. This benefit strategy hasnt posed any negative results for BAI so keeping it in place is a strong recommendation. Also the boost in employee morale that comes from the flexibility of choosing where they will work at any point in time cannot be quantified. This benefit is a unique one that other companies may have to replicate to compete with BAI. Other non-retirement benefits such as parking, paid-time-off and vacation days are pretty much standard from employer to employer and wont pose too much of an influence on which employer an employee opts to work with. Those benefits should remain as they are. Cost Containment Strategy Considerations Tuition Reimbursement Aside from the satisfaction level of employees who receive benefits, the cost of offering such benefits is the biggest concern. Offering employees benefits comprises about 25-33% of that employees total compensation. An employee that is paid $66,000 in salary can cost a company more than $100,000 to employ. With that known, BAI must implement a system that maximizes the value of each dollar spent on an employee benefit. Through interviewing with Berkshire Associates director of human resource management, Lisa Stone, we have found some common flaws that can drastically improve BAIs ability to contain the cost of offering their benefits. Third Party Administration First, Lisa expressed to us that a lot of their administration for these benefits are being conducted by insurance carriers. Even though this agreement shifts a lot of pressure off of employees backs in terms of compliance with regulations, if there are any mistakes BAI can be fined very heavily. The risk of making a mistake is always going to be present when we are talking about compliance with regulations but the burden of the penalty doesnt rest with the insurer. Second, Lisa told us their brokers design a lot of their healthcare options for non selffunded benefits such as healthcare. Letting brokers design a plan that will pay them can be a very big mistake. BAI cannot just assume that their broker wont over insure them in an attempt to create a valuable payout for himself. Brokers arent employed by the insurer or BAI, so their interest is solely personal at the end of it all. Lisa should get more involved in the designing of

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the healthcare options, maybe by eliminating a more costly option like the POS that isnt utilized very heavily by employees. CDHPs The implementation of more CDHPs can be a great cost container. When asked how her employees would respond to the shift to purely CDHPs she responded negatively, our CDHPs are great but we keep other options for our employees in domestic partnerships since the HRA contribution isnt tax exempt for them and employees with dependents who prefer the wide network of providers. With this information we can propose that BAI implement a new CDHP and eliminate the POS option. The elimination of this option will steer employees who dont want to increase price to join CDHPs and everyone who truly needs the PPO option such as domestic partners and families will opt for the PPO. Lastly, reducing the amount recoverable through the life insurance limit slightly, can decrease this premium. The recoverable amount in the case of a non-occupational death is $50,000. This amount is about representative of the average salary in Maryland for one year. The actually average is $48,000 and by reducing everyones limit just $2000 you will notice a decrease in the next plan years premium. Also, communication of the change and what the limit represents can help retain the employees who may feel that there are being shamed out of a benefit. Wellness Program Another potential cost containment strategy BAI can consider is a wellness rewards program. Lisa expressed that BAI doesnt have a wellness rewards system in place and BAI was strongly considering it for the future. These types of programs give discounts on gym memberships and other voluntary efforts to stay healthy. Also rewards for candidates who quit unhealthy habits like smoking and drinking can be another incentive. This program seeks to address the problem of rising healthcare costs by eliminating some common habits that cause increased probability that an individual will need to use healthcare. Some believe these programs are unfair because they punish individuals who already lead healthy lifestyles 3. However, getting individuals who can create costly procedures for themselves through their bad habits to
1.
3

PRO/CON : The Fairness of Health Insurance Incentives. Los Angeles Times

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change their life style can save a lot. If an employee were to drink alcohol every day after work, in 30 years he may need a Conclusion In conclusion, changing benefit plan design doesnt always have to be about what benefits will be cut or an unreasonable increase in price. BAIs main concerns for offering the benefits under the plan going into the future should be mitigate the costs due to inflation and meeting new regulatory compliances under PPACA. Through the shift of benefits, employee feedback and alterations to plans and limits, cost containment while satisfying employees is a very realistic goal in offering employee benefits at Berkshire Associates.

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Works Cited
1. Small Group Market Report last modified October 14, 2008. http://mhcc.maryland.gov/smallgroup/sgm_reform.pdf 2. Burton T. Beam, Jr. Group Benefits: Basic Concepts and Alternatives 12th Edition. (Bryn Mawr, The American College Press) 3. Duke HelfandA Shift Towards Smaller Health Insurance Networks. Los Angeles Times, April 3rd 2011. 4. Brendan Borrell PRO/CON : The Fairness of Health Insurance Incentives. Los Angeles Times, January 3rd, 2011 5. The Patient Protection and Affordable Care Act last modified December 10th, 2010. https://www.cms.gov/LegislativeUpdate/downloads/PPACA.pdf 6. Jones, Mark C. "Health Care Reform Update: Changes Plan Sponsors Should Make This Year." Http://www.pillsburylaw.com/. Pillsbury Law, 8 Sept. 2010. Web. 3 Dec. 2011.<http://www.pillsburylaw.com/siteFiles/Publications/ECB_LifeSciences_Health Care_Alert_FINAL_09-08-2010.pdf>. 7. Meyer, Ann. "Firms Boost Workplace Benefits to Attract, Retain, Tech-savvy Workers - Chicago Tribune." Featured Articles From The Chicago Tribune. Chicago Tribune, 26 Oct. 2009. Web. 2 Dec. 2011. <http://articles.chicagotribune.com/200910-26/news/0910250113_1_employee-retention-perks-workplace-practices>. 8. "Questions and Answers: Keeping the Health Plan You Have: The Affordable Care Act and Grandfathered Health Plans." Health Reform. U.S. Department of Health & Human Services. Web. 07 Dec. 2011. <http://www.healthreform.gov/about/grandfathering.html>.

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