While employer medical and dental plans were originally designed to be supplementary to the publicly funded government plan, as a result of the federal and provincial cutbacks in healthcare services employers and private insurers across this country have had to alter and redesign their medical and dental plans to keep up with emerging trends of higher claims and new cost realities. In an age where publicly covered services continue to be reduced, we are likely to see Corporate Canada’s share continue to increase in the coming years.

In the midst of these economic pressures on the current healthcare system, employees are demanding an enriched company medical and dental benefits plan. While the traditional corporate employee medical and dental benefits plan in Canada provides coverage for semi-private hospital rooms, prescription drugs, dental, chiropractors, physiotherapists, vision care, extended health coverage, and travel medical insurance, employees are asking for more options than ever before. Opinions on what to add are largely influenced by age and experience – items like teeth whitening can compete with orthotics. Older employees want expanded drug coverage, while younger workers are concerned about their deductibles. The end result is employees want choice and employers want/need to contain their costs.

The vast majority of Canadian small and mid-sized businesses offer medical and dental benefits to their workforces by utilizing insurance carriers. With the consolidation frenzy of the last decade, the number of insurance carriers has dwindled in an effort to make the Canadian players more globally competitive. This new, streamlined landscape has been good for the carriers, but not for the small and medium-sized Canadian business, which have been underserved by the carriers focused on delivering shareholder value with big premium clients which are $500,000 or more in annual premiums.

The increasing pressures on the current healthcare system, the consolidation of the insurance industry and the growing employee demand for more flexible and expanded coverage is having the greatest impact on the small and medium-sized Canadian business. With health and dental care coverage escalating by approximately 15% for health and 7% for dental. Small and medium-sized employers are facing uncontrollable and unpredictable costs to their businesses to provide these benefits. Employers have tried to curtail these costs by introducing annual limits, co-insurance, deductibles, and exclusions to their medical and dental plans.

Upon closer review of the average group medical and dental policy for small to mid-size businesses, usually, only 60% to 75% of the overall premium dollars are earmarked for payment for eligible claims. The remaining portions of these premiums are used to pay administration cost, create reserves, pay commissions and earn insurance carriers profits for shareholders.

As an alternative to the traditional medical and dental insurance solution, some employers are choosing to move towards the Administrative Services Only (ASO) model offered by traditional insurance companies and third-party administrators. There are generally 3 components to this model:

a)Self-Insurance – The employer self-insures, assuming the cost of all claims.

b)Stop-Loss Insurance – To reduce the risk of a large employee claim, Stop Loss insurance provided by a traditional carrier or specialty provider is combined with the self-insurance to payout claims beyond a certain level. The premium for this reduced level of insurance is reasonably affordable.

c) Third-Party Administrator (TPA)- In order for CRA to allow the cost for medical and dental plans to be tax-deductible for the employer and the benefits to be non-taxable in the hands of employees the administration of these plans operated through the ASO model must be handled by a third party.

By avoiding a great deal of the administrative costs and reserves incurred by traditional insurance companies, this model allows the employer to pay more claims with every dollar spent and offers greater flexibility when designing a plan. Under the ASO model, the company assumes the cost of predictable claims and purchases Stop-Loss insurance for the catastrophic risk for unpredictable large claims.

When an insurance company assumes a small business’ (under 50 lives) full health and dental risk from $1 to $3,500, the premium is high. Under the Stop Loss conditions, where the risk and expenses for an insurance company start only after the first $3,500 per employee per year for eligible medical and dental expenses, the results employers could see is their costs reduced significantly to as much as 10% – 40% from that of traditional group medical and dental insurance.

ASO and insured plans in action

A small transportation company in Ontario with approximately 70 employees, over the past three years, faced a number of challenges that involved skyrocketing group insurance plan premiums increasing annually at 10%. In a competitive industry with only 5% profit margins, the company had to take immediate action. This company outlined that it wanted to achieve two objectives when reviewing its group insurance plan.

1) Provide an enhanced medical and dental plan that would be attractive to new and existing personnel.

2) Maintain and if possible reduce expenditures on its balance sheet.

After a thorough consultation, the corporate benefits program was reengineered to meet the company’s objectives. This was accomplished by modifying the existing fully insured group plan to an ASO and insured model. After the new solution was implemented, annual premiums went from $403,562 to $239,706, a 40% savings in year one of the new plan and in year two the premiums for ASO and insured plan increased by 5.5% instead of the10% premium increases seen by the traditional group insured plan.

Based on the above assumptions this company will realize accumulative savings by transitioning from the traditional group insured plan to the new ASO and insurance plan totaling $3,345,439 over the next 10 years. Had the employer paid for the entire plan these savings will have been equivalent to the company generating $67 Million of gross revenue during the same 10 year period.

Regardless of whether employers continue with traditional group insurance plans or adopt the ASO model, employers need to review their plan designs and understand where employee spending is occurring. It is strongly recommended that the employer include Stop-Loss insurance coverage with a reputable provider along with a pooled out of province, out of country travel insurance program. Now with the ASO model, the cost of benefits is directly claim driven versus premium driven off the old traditional insurance carrier plan model.

Third-party administrators and insurers will report all claims by the employee by category (drug, dental, paramedical, hospital, vision) to the employer. In accordance with PIPEDA, the employees’ names are not disclosed due to federal privacy laws. With this information, employers together with their administrators are tooled to act to control skyrocketing medical and dental costs. If an employee or their family has large drug claims, a drug cost management program can be initiated.

While it is recommended, if the employer chooses not to include stop-loss insurance coverage in their ASO program there are additional provincial funded drug programs that employees can access that have high drug utilization. This falls outside of the scope of employer-provided coverage but represents an additional option that individuals can access when drugs are not covered by their employer. In the case of Trillium, Ontario’s Provincial drug program, residents must pay an out-of-pocket deductible based on their family net income and the number of their dependent children. The Provincial drug formula is reviewed regularly and not all drugs are covered by these provincial funded drug plans.

Lastly, adopting the ASO model allows employers to provide either Health Spending Accounts (HSA’s) or enhanced benefits for key executives within an organization. An ASO can be structured to provide varying reimbursement limits to different classification of employees (i.e. exec, part-time staff, etc.). Each employee classification can be assigned an annual reimbursement limit, with different classes of employees with differing reimbursement limits.

In this competitive employment environment, employers looking to attract and keep key people, are finding that offering enhanced executive medical and dental plans gives these employers an edge over their competitors aiming to achieve the same results. Enhanced executive medical coverage using the ASO model for key people within an organization in addition to traditional health care coverage can include the rest of an individual’s costs, such as the following:

• insurance premiums paid by the executive/employee or the individual’s spouse for private health and dental plans;
• cosmetic dental and medical treatment;
• over-the-counter drugs, provided they are prescribed by a physician;
• drugs for conditions sometimes excluded under conventional plans;
• facilities and services – special school, alcohol/drug addiction, nursing home care, institution for mental or physical handicap, licensed private hospital, semi-private or private charges in a hospital, care of a person who has been certified as mentally incompetent, care of a blind person, and full-time attendants in a nursing home, fertility clinics;
• laser eye surgery;
• professional services of a dietician, acupuncturist, psychologist or nutritionist;
• dental care (preventive/restorative/orthodontic); and,
• medical equipment and devices.

Note: Please refer to CRA guidelines for specific details.

Individually, employers have no say over the direction of government policy towards healthcare or how the Canadian economy will behave. But what they do have is complete control over how they choose to navigate with their employees through these challenging times by providing medical and dental benefit solutions that address the needs of both their company and their people. It is how corporations act during these periods of transition that will result in creating goodwill – and profitable results.