Week 3: Consumers Service, Financial Systems and Regulatory Affairs

Consumer Service Expenses (15 minutes)

  1. Over the past five years, what is the average percentage of your annual expenses (not including claims paid) that are devoted to each of the following consumer services:

    1. development of consumer guides and newsletters; and
    2. development of web-based applications to assist consumers to use your health plans.

  2. Explain who is responsible for your company's contacts with consumers or their representatives (e.g., family members, legislators, counsel). Identify the number of staff and proportion of health plan administration expenses devoted on an annual average to responding to calls, e-mails and other questions from consumers about their health plan.

    1. Explain the different practices and expenses in marketing to small versus large employers.
    2. Explain steps your company has taken to reduce the cost of selling and marketing to employers.

  3. During the 2008 calendar year, how many mailings did your health plan make to your members or potential members? If your health plan communicates with members via e-mail or other electronic means, how many such electronic messages did your health plan send to members?
  4. How does your health plan make consumers aware of changes to your web-based information?

  5. Does your health plan issue a periodic newsletter for members? During the 2008 calendar year, how often did you produce the newsletter and how did you distribute it to members? Describe the normal content included within the newsletter and the reasons that your health plan continues to provide this to your members.

  6. For calendar years 2006, 2007 and 2008, how many phone calls did your health plan receive from consumers about their health plan? How many staff are dedicated to responding to phone calls from members?

    1. Categorize the reasons for the calls and identify the proportion of calls that required your health plan's staff to respond to complaints about your health plan.
    2. Identify the proportion of calls that are associated with members in the following markets:
      1. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    3. Explain the process that your company uses to identify trends in complaints and ways that your health plan uses this information to address issues in your health plan.

  7. During calendar years 2006, 2007 and 2008, how many letters and e-mails did your health plan receive from consumers about their health plan? How many staff are dedicated to responding to letters and e-mails from members?

    1. Categorize the reasons for the letters and e-mails and identify the proportion of letters and e mails that required your health plan's staff to respond to complaints about your plan.
    2. Identify the proportion of letters and e-mails that are associated with members in the following markets:
      1. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    3. Explain the process that your company uses to identify trends in complaints and ways that your health plan uses this information to address issues in your health plan.

  8. Explain how consumer service expenses may differ among the products that you offer, identifying the different consumer services expenses for the following types of products:

    1. Medicare/Medicaid;
    2. Individual/small employer (50 or fewer eligible employees) insured plans;
    3. Large employer (over 50 eligible employees) insured plans; and
    4. Administration of self-funded plans.

  9. Identify how your company measures consumer satisfaction with the way that your company administers its health plan. If your company surveys members, explain the frequency of the surveys, present any results and explain the ways that your company uses the results and what your company has done over the past five years to change your health plan administrative activities and explain for each of these changes how it has improved service and/or reduced your health plan administrative expenses.

Financial Systems (15 minutes)

  1. Explain who is responsible for the managing the systems gathering financial information, collecting revenue, making payments and properly keeping track of all the accounting systems of your health plan.

    1. Explain the role of the financial manager, the number of staff working in this area, and the average proportion of your health plan's expenses tied to the work done managing your financial systems. Explain the functions of the staff and the reasons that your health plan devotes the noted level of staff and resources to these functions.
    2. Explain the different practices and expenses in reference to each of the following markets:
      1. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    3. Explain steps your company has taken to improve your systems and, where possible, reduce the cost of your financial systems, including any analysis done to invest in new systems or outsource certain functions that are or have been done by health plan staff.

  2. Explain the types of audits and examinations (internal and external) that are conducted of your health plan operations and the following details about these audits and examinations:

    1. the reasons they are conducted;
    2. the frequency at which they are conducted;
    3. the persons or firms that conduct them;
    4. the average annual cost of conducting them; and
    5. e. internal staff time, resources and cost necessary to prepare materials for them.

  3. Explain the role of the Finance Committee and Audit Committee of your health plan's Board of Directors. Who is on these committees, to whom these committees report, and the resources necessary to respond to the needs of these committees?

  4. Explain who is responsible for managing the investments of your health plan.
    1. Explain the role of the investment manager, the number of staff working in this area, and the average proportion of your health plan's expenses tied to the work done managing investments. Explain the functions of the staff and the reasons that your health plan devotes the noted level of staff and resources to these functions.
    2. Explain the different practices and expenses in reference to each of the following markets:
    1. Medicare/Medicaid;
    2. Individual/small employer (50 or fewer eligible employees) insured plans;
    3. Large employer (over 50 eligible employees) insured plans; and
    4. Administration of self-funded plans. Explain steps your company has taken to reduce the cost of these activities.

  5. Explain who is responsible for managing the debt service of your health plan.
    1. Explain the role of the debt service manager, the number of staff working in this area.
    2. Explain the functions of the staff and the reasons that your health plan devotes the noted level of staff and resources to these functions.
    3. Explain the different practices and expenses in reference to each of the following markets:
      1. i. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    4. Explain steps your company has taken to reduce the cost of these activities.
  6. What benchmarks do you use to analyze your business?

Regulatory Affairs (15 minutes)

  1. Explain who is responsible for monitoring legislative and regulatory actions. Identify the number of staff and proportion of administration expenses devoted on an annual average to responding to regulators or following legislative and regulatory activities.

    1. Explain the different practices and expenses in reference to each of the following markets:
      1. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    2. Explain steps your company has taken to reduce the cost of regulatory compliance activities.

  2. Explain who is responsible for your company's reports to state, federal and other government regulators. Identify the number of staff and proportion of administration expenses devoted on an annual average to responding to regulators or following regulatory activities.

    1. Explain the different practices and expenses in reference to each of the following markets:
      1. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    2. Explain steps your company has taken to reduce the cost of regulatory compliance activities.

  3. For the 2008 calendar year, please provide a list of external reports that your company prepared, the agencies who receive them, the frequency of the reports, and the resources required for their preparation. (This may include but not be limited to Bank/Debt Service, SEC, NAIC, etc. in addition to regulatory filings discussed in the previous section.)

  4. Identify the expense and staff resources associated with each report. List and describe the need for outside, independent consultants (such as CPAs and Actuaries), as required by statute and regulation, that provide expertise not available in the Company, and the contribution to administrative costs. Identify which reports you believe are duplicative.

  5. What regulatory requirements are duplicative or provide little or no value to the member compared to the amount of time and resources it takes to meet the requirements?