Preferred Executive Plan (PEP)

The Primary Value Plan (PVP) is an affordable, basic health benefits program available to Southern California employers and trust funds. PVP is a self-funded ERISA plan that is designed to function very much like a fully insured HMO. PVP unites the best aspects of managed care (e.g., medical utilization cost control techniques) with the administrative cost efficiencies of self-funded plans. PVP creates a direct partnership between the employer (the payer of health plan costs) and physicians (the providers of care).

Employee Health Systems developed PVP in conjunction with Vector Risk Analysis, TPAC Underwriters, and Full Circle Solutions.

		Employee Health Systems is a medical management firm and provider network serving self-funded ERISA and managed care patients since 1985. EHS is fully delegated by all of the health plans with whom it contracts to provide care. ACA Administrators, an affiliate of EHS, serves as the third party administrator (TPA) providing the administrative and claims management expertise for the PVP program. Unlike most TPAs that only provide billing and claim-paying services, EHS and ACA are managed care companies, and as a result take on the added responsibilities of utilization management, case management, quality management and provider credentialing. In many TPAs, these functions are outsourced and subcontracted to other third parties. In managed care, it all resides under one roof. Thus, in addition to claims personnel, EHS and ACA employ physicians and nurses to oversee referrals, follow patients who go to the hospital, and perform other clinical activities and requirements. Because EHS and ACA are so heavily involved in managed care, we perform to standards required by HMOs and other managed care regulators. For example, clean claims are required to be processed and paid within 30 days. Routine referrals must be processed within 3 business days. These more stringent protocols are not required in a typical TPA setting. However, at EHS and ACA, all business processes operate at the more stringent managed care levels. EHS and ACA utilize a full-blown state-of-the-art HMO computer system, HealthTrio Xpress, which includes all of the functions of an insurance company (and hence, TPA), and is flexible enough to process multiple lines of business with multiple fee schedules. As a result, EHS and ACA are currently responsible for and take care of more than 45,000 people in multiple states. By already servicing this business, startup times, training and other expenses are reduced.
		Vector Risk Analysis and TPAC Underwriters provide the underwriting and employer stop loss insurance arrangements through Lloyd's of London. Vector Risk Analysis, through its principal Hobson Carroll FSA, has been successfully developing health care programs for domestic and foreign insurers for over twenty years. VRA developed the actuarial basis for PSP. TPAC Underwriters was established in 1991 as a managing general underwriter and has been underwriting and managing health care insurance plans for several insurers since its inception. TPAC is the authorized underwriting company for Lloyd's of London and Pan American Life.
		Full Circle Solutions, established in 2000, serves as the Exclusive Provider Organization (EPO) for PSP. The FCS network was organized and contracted to provide employers and trust funds with direct access to a health care delivery system that provides quality cost effective care without the administrative costs and limitations of an HMO. The FCS Network consists of medical groups (including EHS) and hospitals that have extensive experience in providing health care in a managed care environment to thousands of Californians.

PVP has been designed to provide affordable health care benefits to groups with fifty or more covered employees as an alternative to traditional health plans. PVP is offered as a self-funded ERISA plan that contracts directly with health care providers. Typically, PVP will be priced 20% to 40% below that of a traditional HMO plan. This is achieved by including plan design features that reduce claim costs, provide a stable plan of benefits, and utilize providers who understand managed care and can reduce overall health expenditures.

Benefit Limitations

PVP benefits are limited to $50,000 annually and $250,000 lifetime per person. The benefit, however, is based on paid claims, not retail costs. The value of this limitation is greatly enhanced because PVP benefits are paid, with the exception of emergency expenses, to contracted providers who have agreed to accept payment-in-full at substantially reduced rates.

PVP further limits prescription benefit reimbursements to generic drugs only. While much is heralded about new drugs being introduced to the market almost daily, many of these new drugs are very expensive. Most conditions are treatable with generic drugs. Brand name drugs are offered through PVP to members on a discounted basis.

Finally, out-of-network medical expenses are not covered except for emergency services and coverage is limited. Please review the attached PVP Schedule of Benefits.

Elimination of State-Mandated Benefits

State-mandated benefits, which in many cases are the result of intense lobbying by special interest groups, can add 10% to 15% to the cost of fully insured plans. PVP, as a self-funded ERISA program, is not required to offer State-mandated benefits; only to comply with federal rules and regulations governing health benefit plans.


Reduced Overhead Expenses

PVP is not burdened with the same overhead expenses as are fully insured HMOs. The following are just some of the expenses that are added to health plans that provide no benefit to the employer, plan sponsor, or plan member:

		Corporate Overhead
		Marketing Costs (including advertising, public relations and government lobbying)
		Salaries and Commissions paid to internal staff
		Government Compliance Costs
		Shareholder Profit

PVP has been designed as a stand-alone product, or it can be offered on a class-basis alongside Premier Solutions Plan (PSP) and Preferred Executive Plan(PEP), two other health benefit programs offered through Employee Health Systems. PVP may be offered as an employee option alongside other health plans as long as employer contributions remain on a "defined contribution basis" for PVP participants. PVP will also accept dependents of employees covered under other plans offered by the employer, if the employer has been offered dependent coverage. Employers who adopt PVP will be billed 100% of the anticipated cost of the plan. The cost of PVP consists of three elements - claim funds, insurance premiums, and administrative costs including broker commissions if applicable.

	Claim Funds. Two claim funds are established.
		One is used to pre-pay professional services (e.g., doctors, etc.) on an advance-funded basis. It is not considered capitation; however, the employer is not responsible for providing additional funds if professional utilization exceeds expected projections. This is because professional incurred claims costs are accumulated at 50% of Medicare allowable, and is reconciled against the advance funding contributions. Any deficit that may be due to a provider group will be the responsibility of Full Circle Solutions.
		The second claim fund, called the Employer Claim Fund Account (ECFA), is used to pay for hospital, technical, and prescription claim costs of the plan, as defined in the employer's Plan Document. If, at the end of a Plan year plus six months, the ECFA has a positive balance with no claims having been paid by the stop loss carrier for the plan year, then any balance will be returned to the employer as excess plan contributions.
	Insurance. Aggregate stop loss insurance is provided on an incurred-in-12-months/paid-in-18-months claim basis through Lloyd's of London. In the event that the ECFA does not have sufficient funds, then the stop loss coverage will provide the needed funds to the ECFA as its obligation under the terms of the stop loss agreement. Any deficit in the ECFA for expenses incurred and paid on behalf of eligible plan members that are covered under the terms of the Plan Document adopted by the employer will be the responsibility of the stop loss carrier.
	Administrative Expenses. Administrative expenses are limited to benefits administration, network access fees, and state taxes and broker compensation, if applicable.
	Rates. Rates quoted are based on the employee census provided. Any material change in the age, sex and number of dependents covered will change the final rates. To have a broker contact you, click here.

For more details on PVP's Schedule of Benefits, click on the link below. [Link to PVP Schedule of Benefits]

PVP SCHEDULE OF BENEFITS
Maximum Annual Benefit			$50,000 per person
Maximum Lifetime Benefit			$250,000 per person
Exclusive Provider Network			Full Circle Solutions (FCS)
Deductible			None
Co-payments
		Primary Care Doctor's Visits	$10
		Specialists Doctor's Visits	$25
		Professional Surgical Services	$200 per surgery
		Professional Maternity Services	$200 per delivery
		Professional Lab & X-Ray Services	$10 (waived if done in a doctor's office the same day as an office visit)
		Preventive Care Services	$10
		Well Baby Care Services	$10
		Chiropractic Visits	$10
		Emergency Room Visit
		In-Network	$50 (waived if admitted as an inpatient)
		Out-of-Network	$100
		Hospital confinement	$250 per Hospitalization
		Outpatient Facility Services	$250 per Facility per day
		Home Health Care Visits	$25
		Ambulance	$100 per occurrence
Out of Pocket Maximum
		In Network	$1,000 per person per year
			$3,000 per family per year
		Out of Network	There is no limit to out of pocket expenses for out-of network services
Hospital Charges
All non-emergency Inpatient and Outpatient services must be pre-approved by the members Provider Group
		Inpatient Hospital Benefits	100%
		Outpatient Hospital Benefits	100%
		Maternity Care Benefits	100%
		Newborn Care Benefits	100%
		Skilled Nursing Facility (following an inpatient stay)	100%
		Hospice Care	100%
Professional Charges
Medical costs that exceed the usual, reasonable and customary charges are not covered
		Home, Office & Hospital Visits	100%
		Surgery, Including Assistant Surgeon & Anesthetis	100%
		Maternity Care Services	100%
		Immunizations	100%
		Annual Mammography	100%
		Well Baby Care	100%
		Preventive Care Services (Authorized through the Primary Care Physician)	100%
		Lab & X-Ray Services	100%
		Chiropractic Services (Maximum of 15 visits per year per person)	100%
Other Medical Services
		Ambulance	$500 Maximum annual plan benefit
		Chemotherapy Drugs (intravenously administered)	100%
		Durable Medical Equipment	$250 Maximum annual plan benefit
		Home Health Care	100%
		Injectable Medications (When administered as an outpatient procedure)	100%
		Outpatient Rehabilitation Therapy	100%
Mental Health Services (Includes Alcohol and Drug Abuse)
		Inpatient Hospitalization	Not covered
		Outpatient Care	$25 per visit co-payment. Max of 12 visits/person/year
Outpatient Prescription Drugs
		Generic Drugs	$8 Co-payment
		Brand Name Drugs	Not covered as a plan benefit. Discount card provided
Out of Network Benefits Limited to Emergency Services Only
		Professional Services	50% of Medicare Allowable
		Hospital Inpatient Services	$660/day for all inpatient care to a maximum of 15 days per confinement
		Emergency Room Services	50% of Medicare Allowable to a max benefit of $2000 per occurrence

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     Premier Solutions Plan (PSP)

The Premier Solutions Plan (PSP) is a comprehensive group health benefits program available to Southern California employers and trust funds. PSP is a self-funded ERISA plan that is designed to function very much like a fully insured HMO. PSP unites the best aspects of managed care (e.g., medical utilization cost control techniques) with the administrative cost efficiencies of self-funded plans. PSP creates a direct partnership between the employer (the payer of health plan costs) and physicians (the providers of care).

Employee Health Systems developed PSP in conjunction with Vector Risk Analysis, TPAC Underwriters, and Full Circle Solutions.

		Employee Health Systems is a medical management firm and provider network serving self-funded ERISA and managed care patients since 1985. EHS is fully delegated by all of the health plans with whom it contracts to provide care. ACA Administrators, an affiliate of EHS, serves as the third party administrator (TPA) providing the administrative and claims management expertise for the PSP program. Unlike most TPAs that only provide billing and claim-paying services, EHS and ACA are managed care companies, and as a result take on the added responsibilities of utilization management, case management, quality management and provider credentialing. In many TPAs, these functions are outsourced and subcontracted to other third parties. In managed care, it all resides under one roof. Thus, in addition to claims personnel, EHS and ACA employ physicians and nurses to oversee referrals, follow patients who go to the hospital, and perform other clinical activities and requirements. Because EHS and ACA are so heavily involved in managed care, they perform to the standards required by HMOs and other managed care regulators. For example, clean claims are required to be processed and paid within 30 days. Routine referrals must be processed within 3 business days. These more stringent protocols are not required in a typical TPA setting. However, at EHS and ACA, all business processes operate at the more stringent managed care levels. EHS and ACA utilize a full-blown state-of-the-art HMO computer system, HealthTrio Xpress, which includes all of the functions of an insurance company (and hence, TPA), and is flexible enough to process multiple lines of business with multiple fee schedules. As a result, EHS and ACA are currently responsible for and take care of more than 45,000 people in multiple states. By already servicing this business, startup times, training and other expenses are reduced.
		Vector Risk Analysis and TPAC Underwriters provide the underwriting and employer stop loss insurance arrangements through Lloyd's of London. Vector Risk Analysis, through its principal Hobson Carroll FSA, has been successfully developing health care programs for domestic and foreign insurers for over twenty years. VRA developed the actuarial basis for PSP. TPAC Underwriters was established in 1991 as a managing general underwriter and has been underwriting and managing health care insurance plans for several insurers since its inception. TPAC is the authorized underwriting company for Lloyd's of London and Pan American Life.
		Full Circle Solutions, established in 2000, serves as the Exclusive Provider Organization (EPO) for PSP. The FCS network was organized and contracted to provide employers and trust funds with direct access to a health care delivery system that provides quality cost effective care without the administrative costs and limitations of an HMO. The FCS Network consists of medical groups (including EHS) and hospitals that have extensive experience in providing health care in a managed care environment to thousands of Californians.

PSP has been designed to provide comprehensive health care benefits to groups with thirty or more covered employees as an alternative to traditional health plans. PSP is offered as a self-funded ERISA EPO plan that contracts directly with health care providers.

PSP has been designed as a stand-alone product, or it can be offered on a class-basis alongside Primary Value Plan (PVP) and Preferred Executive Plan (PEP), two other health benefit programs offered through Employee Health Systems. Employers who adopt PSP will be billed 100% of the anticipated cost of the plan. The cost of PSP consists of three elements - claim funds, insurance premiums, and administrative costs including broker commissions if applicable.

	Claim Funds. Two claim funds are established.
		One is used to pre-pay professional services (e.g., doctors, etc.) on an advance-funded basis. It is not considered capitation; however, the employer is not responsible for providing additional funds if professional utilization exceeds expected projections. This is because professional incurred claims costs are accumulated at 50% of Medicare allowable, and is reconciled against the advance funding contributions. Any deficit that may be due to a provider group will be the responsibility of Full Circle Solutions.
		The second claim fund, called the Employer Claim Fund Account (ECFA), is used to pay for hospital, technical, and prescription claim costs of the plan, as defined in the employer's Plan Document. If, at the end of a Plan year plus six months, the ECFA has a positive balance with no claims having been paid by the stop loss carrier for the plan year, then any balance will be returned to the employer as excess plan contributions.
	Insurance.  Aggregate stop loss insurance is provided on an incurred-in-12-months/paid-in-18-months claim basis through Lloyd's of London. In the event that the ECFA does not have sufficient funds, then the stop loss coverage will provide the needed funds to the ECFA as its obligation under the terms of the stop loss agreement. Any deficit in the ECFA for expenses incurred and paid on behalf of eligible plan members that are covered under the terms of the Plan Document adopted by the employer will be the responsibility of the stop loss carrier.
	Administrative Expenses. Administrative expenses are limited to benefits administration, network access fees, and state taxes and broker compensation, if applicable.
	Rates. Rates quoted are based on the employee census provided. Any material change in the age, sex and number of dependents covered will change the final rates. To have a broker contact you, click here.

PSP SCHEDULE OF BENEFITS
Maximum Annual Benefit			$1,000,000 per person
Exclusive Provider Network			Full Circle Solutions (FCS)
Deductible			None
Co-payments
		Doctor's Office Visits	$10
		Allergy Testing/Treatment	$10
		Preventive Care Services	$10
		Well Baby Care Services	$10
		Urgent Care Visits	$30
		Chiropractic Visits	$10
		Emergency Room Visit (waived if admitted as inpatient)	$60
		Hospital confinement	$300
Out of Pocket Maximum
		In Network	$1,000 per person / $2,000 per family
		Out of Network	There is no limit to out of pocket expenses for out-of network services
Hospital Charges
All non-emergency Inpatient and Outpatient services must be pre-approved by the members Provider Group
		Inpatient Hospital Benefits	100%
		Outpatient Hospital Benefits	80%
		Maternity Care Benefits	100%
		Newborn Care Benefits	100%
		Skilled Nursing Facility (( up to 100 consecutive days after IP stay)	100%
		Hospice Care (up to 180 days in a facility)	100%
Professional Charges
Medical costs that exceed the usual, reasonable and customary charges are not covered
		Home, Office & Hospital Visits	100%
		Surgery, Including Assistant Surgeon & Anesthetis	100%
		Maternity Care Services	100%
		Immunizations	100%
		Annual Mammography	100%
		Well Baby Care	100%
		Preventive Care Services (Authorized through the Primary Care Physician)	100%
		Lab & X-Ray Services	100%
		Chiropractic Services (max of 50 visits / year / person)	100%
Other Medical Services
		Ambulance (Air Ambulance is excluded)	80%
		Chemotherapy Drugs (Intravenously Administered)	80%
		Durable Medical Equipment	80%
		Home Health Care	80%
		Injectable Medications (When administered as an outpatient procedure)	80%
		Outpatient Rehabilitation Therapy (up to 60 visits per calendar year	80%
		Outpatient Facility Charges	80%
		Tubal Ligation	80%
		Vasectomy	80%
Mental Health Services (Includes Alcohol and Drug Abuse)
		Inpatient Hospitalization (max of 10 days per calendar year)	$600 per day
		M. D. Supervised Residential and Day Treatment Centers counts as ½ day towards Calendar year maximum	$300 per day
		Outpatient Care (25 visits per calendar year maximum)	$60 per visit
Outpatient Prescription Drugs
		Generic Drugs (mandatory substitution required)	$8 Co-payment
		Brand Name Formulary	Not covered as a plan benefit. Discount card provided
Out of Network Benefits Limited to Emergency Services Only
		Professional Services	100% of Medicare Allowable
		Hospital Inpatient Services (max of 15 days per confinement)	100% of Medicare Allowable
		Emergency Room Services	100% of Medicare Allowable

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     Preferred Executive Plan (PEP)

The Preferred Executive Plan (PEP) is a comprehensive PPO health benefits program available to Southern California employers and trust funds. PEP is a $0/$500 deductible, $1,000,000 maximum PPO plan with a $20 co-payment for in-network office visits and a $15/$25/$40 drug benefit card. The co-insurance on this program is 80% in-network and 60% out-of-network, with a $1,500/$3,000 out-of-pocket maximum per person. PEP utilizes a comprehensive national PPO network provided by ppoNEXT. ppoNEXT is one of the largest and fastest growing preferred provider organizations in the country, encompassing more than 400,000 physician providers and 3,800 healthcare facilities nationwide.

			In-Network	Out-of-Network
Deductible			None	$500
Co-payments
		Doctor's Office Visits	$15	None
		Allergy Testing/Treatment	$15	None
		Preventive Care Services	$15	None
		Well Baby Care Services	$15	None
		Urgent Care Visits	$25	None
		Chiropractic Visits	$15	None
		Emergency Room Visit (waived if admitted as an inpatient)	$50	None
		Hospital confinement (waived if admitted to a Full Circle Solutions contracted hospital)	$500	None
Out of Pocket Maximum
		In-Network	$1,500 per person
			$3,000 per family
		Out-of-Network	There is no limit to out of pocket expenses for out-of network services. Only member’s Benefit Percentage Payments accumulate toward the Out-of Pocket Maximum for in network expenses
Hospital Charges
All non-emergency Inpatient Admissions must be pre-approved by ACA Administrators. Non-compliance with pre-admission certification will result in a 50% reduction of benefit payment.
		Inpatient Hospital Benefits	90%	60%
		Outpatient Hospital Benefits	90%	60%
		Maternity Care Benefits	90%	60%
		Newborn Care Benefits	90%	60%
		Skilled Nursing Facility (Up to 100 consecutive days following an inpatient stay)	90%	60%
		Hospice Care (up to 180 days in a facility)	90%	60%
Professional Charges
		Home, Office & Hospital Visits	90%	60%
		Surgery, Including Assistant Surgeon & Anesthetist	90%	60%
		Maternity Care Services	90%	60%
		Immunizations	90%	60%
		Annual Mammography	90%	60%
		Well Baby Care	90%	60%
		Preventive Care Services	90%	60%
		Lab & X-Ray Services	90%	60%
		Chiropractic Services (Maximum of 100 visits per year per person)	90%	60%
Other Medical Services
		Ambulance (air ambulance is excluded)	90%	60%
		Chemotherapy Drugs (intravenously administered)	90%	60%
		Durable Medical Equipment	90%	60%
		Home Health Care	90%	60%
		Injectable Medications (When administered as an outpatient procedure)	90%	60%
		Outpatient Rehabilitation Therapy (Up to 60 visits per calendar year)	90%	60%
		Outpatient Facility Charges	90%	60%
		Tubal Ligation	90%	60%
		Vasectomy	80%	60%
Mental Health Services (Includes Alcohol and Drug Abuse)
		Inpatient Hospitalization (max of 10 days per calendar year)	$600 per day
		M.D. Supervised Residential and Day Treatment Centers counts as ½ day towards calendar year maximum	$300 per day
Outpatient Prescription Drugs
		Generic Drugs (mandatory substitution required)	$10 Co-payment
		Brand Name Formulary	$20 Co-payment
		Brand Name Non-Formulary	$40 Co-payment