Canadian Drug Insurance Pooling Corporation
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Canadian Drug Insurance Pooling Corporation. Scott Heard Vice-President, Sales and Marketing Group Insurance. A partner you can trust. Toronto: November 21, 2012. Our ambition is to ‘ be recognized by our clients as the best service provider of group benefits ’. Agenda.

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Canadian drug insurance pooling corporation

Canadian Drug Insurance Pooling Corporation

Scott HeardVice-President, Sales and MarketingGroup Insurance

A partner you can trust.

Toronto: November 21, 2012


Our ambition is to be recognized by our clients as the best service provider of group benefits

Our ambition is to ‘be recognized by our clients as the best service provider of group benefits’.


Agenda

Agenda

Rationale for the program

Benefits for plan sponsors, plan members, and advisors

How does it work?

Protection from adverse selection

Governance and administration

Impact on advisors, next steps, and timelines


Canadian drug insurance pooling corporation

Rationale for the program


Rationale for the program

Rationale for the program

  • Growing concerns over sustainability

    • ESC 2011 Drug Trend Report

      • Biologic drug claims growing by 12 per cent per year

      • Expected to account for 33% of drug spending in 2014

    • CLHIA data

      • 20% annual growth of claims over $25,000 since 2008

  • Increased duration of recurring, high cost claims

    • Recurring high cost drug claims for relatively young people

  • Increased incidence of high cost claims

    • High cost medications increasingly prescribed to treat cancer, auto-immune conditions and other rare diseases

    • Highly effective and very costly treatment


Rationale for the program1

Rationale for the program

  • CLHIA poll

    • 1/3 of small-medium employers would consider making changes to their drug plans if premiums were to increase by 25%

  • The industry pooling program ultimately helps ensure that millions of Canadians can continue to access the prescription drugs they need, regardless of whether they or their colleagues require a high cost, recurring drug.


Canadian drug insurance pooling corporation

Sun Life

Union Life

Western Life

Twenty four insurers, who collectively account for 100% of supplemental group health business in Canada are participating as Founding Members


Canadian drug insurance pooling corporation

Benefits for Plan Sponsors, Plan Members, and Advisors


Benefits for plan sponsors

Benefits for Plan Sponsors

  • Availability

    • All fully insured groups will continue to be able to purchase group extended healthcare coverage

  • Affordability

    • At a reasonable price even after the incidence of a large recurring drug claim(s)

  • Transferability

    • Able to select the participating insurer of their choice

  • Competition

    • The solution will continue to encourage active and vigorous market competition


Benefits for plan members

Benefits for Plan Members

  • Sustainability of coverage

    • Able to continue to receive coverage through their employer even in the face of a high cost drug claim

  • Job mobility

    • Change of employers won’t jeopardize coverage

  • Protection from financially catastrophic occurence

    • 1,900 individuals covered by fully insured plans in Canada had annual drug claims exceeding $25,000 in 2010


Benefits for advisors

Benefits for Advisors

  • Continued market access for group healthcare benefits for fully insured groups

  • Catastrophic claims will not affect price

    • Even after the incidence of a large recurring drug claim

  • Competitive market conditions restored

  • Limited changes to advisors’ operations


Canadian drug insurance pooling corporation

How does it work?


How does it work

How does it work?

  • The agreement covers only “fully insured plans"

  • Fully insured plans do not include

    • Administrative Services Only (ASO)

    • Refund accounting (includes any element of premium refund to client)

    • Stop loss plans


How does it work1

How does it work?

  • Insurers must place all large drug claims (fully-insured only) in a self-administered pool

    • Extended healthcare Policy Protection Plan:EP3

  • Insurers cannot renewal rate based on the experience of a specific group

    • The number or value of pooled drug claims for a particular plan sponsor cannot be considered in setting renewal rates for that group

    • Favorable and unfavorable experience of a particular plan sponsor will be ignored in setting rates

  • Insurers cannot experience rate and price for new business based on a particular plan sponsor’s pooled drug claims


How does it work2

How does it work?

  • Individual insurers can set premiums based on

    • The experience of its entire EP3 pool

    • Any other experience criteria that is not client specific

  • Drug and non-drug health benefits can be pooled together

    • EP3 rules apply to drug portion only of pooled benefits

    • Insurers are required to have processes that can demonstrate that they are following the rules of EP3 for the drug portion


How does it work3

How does it work?

  • Elements of the EP3 pools can be customized by each insurer include:

    • Pricing

    • Pooling threshold (subject to a cap of $25,000)

    • Pooling at individual level or certificate level

      • Industry pool managed at certificate level

    • Application of co-payments or deductibles

      • Subject to a cap of $1,000 for deductibles

    • Formulary design

    • etc.

  • Insurers can establish multiple EP3 solutions for different market segments


How does it work4

How does it work?

  • Industry pooling is managed at a certificate level

  • Thresholds that must be satisfied to qualify for the industry pool

  • Drug claims must exceed $50,000 for at least two consecutive years

  • In year two and in each subsequent year where the drug claims exceed $25,000, the industry pool will cover 85% of the amount over $25,000 to a maximum of $400,000 per year

  • The largest drug claim that could be fully pooled for a given cap is $400,000 / 0.85 + $25,000 = $496,558

  • If a certificate falls below $25,000 for 2 consecutive years, it is no longer eligible and would need to re-qualify

  • Amounts beyond the cap will be 100% borne by the primary insurer.

  • $50,000 threshold is the "Initial Threshold"

  • $25,000 threshold is the "Ongoing Threshold"


  • How does it work5

    How does it work?

    • For first three years of the pooling, the thresholds are

      • 2012: $25,000 and $50,000

      • 2013: $25,000 and $50,000 (1st year of pooling)

      • 2014: $27,500 and $55,000

      • 2015: $30,000 and $60,000

    • The CDIPC board will adjust the thresholds to maintain an appropriate balance

      • Ensure that the pool stays a relatively constant size

      • Do not jeopardize the principle of transferability in the market


    How does it work6

    How does it work?

    • For first three years of the pooling, the industry cap is

      • 2012: $400,000

      • 2013: $400,000 (1st year of pooling)

      • 2014: $400,000

      • 2015: $500,000

    • The CDIPC board is responsible for adjusting the cap as appropriate on a go forward basis


    How does it work7

    How does it work?

    • Pool 1 – Residents of

      • Alberta

      • Ontario

      • Nova Scotia / New Brunswick / Newfoundland and Labrador / P.E.I.

      • Yukon

      • North West Territories

      • Nunavut

    • Pool 2 – Residents of Quebec

      • For costs not covered under the Quebec Drug Insurance Pooling Corporation

    • Pool 3 – Residents of pharmacare provinces

      • British Columbia

      • Manitoba

      • Saskatchewan


    How does it work8

    How does it work?

    • Participating insurers will share total pooled drug claims

      • Based on each participating insurer’s market share of total paid drug claims for all insured business in the applicable provinces for that pool

      • Any group drug plan that, by design, could never submit a claim to the pool is excluded from the market share calculation for the purposes of sharing pooling costs


    How does it work9

    How does it work?

    • The types of claims that are eligible to be pooled will vary depending on the pool


    Canadian drug insurance pooling corporation

    Protection from Adverse Selection


    Protection from adverse selection

    Protection from Adverse Selection

    • Pre-existing exclusions apply to existing claims of "new" eligible groups (e.g. an ASO group becomes a fully insured group, or a sponsor initiating drug coverage for the first time).

    • Pre-existing exclusions do not apply to existing drug claims of groups with Founding Members that were fully insured group plans as of June 7, 2011


    Canadian drug insurance pooling corporation

    Governance and Administration


    Governance and administration

    Governance and Administration

    • A not-for-profit corporation has been established

      • Canadian Drug Insurance Pooling Corporation (CDIPC)

      • Board comprised of 12 members plus 1 Ex Officio (CLHIA)

      • Permanent Executive Director will be hired to manage corporation

    • CDIPC compliant with Industry Canada standards

      • By-laws and powers have been reviewed and customized by the working group

    • Aspects of the program that will be overseen and managed by a Board of Directors

      • Eligibility

      • Termination

      • Member rights

      • Board of Directors

      • Administration


    Governance and administration1

    Governance and Administration

    Industry Pool

    CDIPC

    Insurer C

    Insurer D

    Insurer B

    Insurer A

    • Governance & Admin

    • TRANSPARENT TO SPONSORS

    • Administers industry pool and ensures insurers comply with EP3 and Industry Pool standards

    • TRANSPARENT TO SPONSORS

    • Helps insurers sustain the costs of providing EP3 protection by pooling large recurring drug claims

    • Industry Pool

    • IMPACTS FOR EMPLOYERS

    • Mandates internal pooling for all fully-insured plans

    • Cannot experience rate clients based on pooled drug claims

    • If bidding on new business, cannot experience rate prospective new clients (already with another insurer) based on pooled drug claims

    • All other aspects of design of EP3 are customizable and a source of competition (price, pooling threshold, formulary design etc.)

    • EP3


    Canadian drug insurance pooling corporation

    • Impact on Advisors,

    • Next Steps, and Timelines


    Impact on advisors next steps and timelines

    Impact on Advisors, Next Steps, and Timelines

    • Advisors should be aware that

      • Insurers will be asking for more information than in the past on prospective new business

        • Copies of plan sponsors’ existing EP3 certificate

        • Copies of experience reports – including what is included or excluded from the experience

      • Information provided by insurers:

        • Every eligible group plan will receive each year an inter-company EP3 certificate outlining the broad terms of their Policy Protection Plan (EP3) and any excluded pre-existing claims, respecting privacy requirements


    Impact on advisors next steps and timelines1

    Impact on Advisors, Next Steps, and Timelines

    • Insurers bidding on new business cannot consider the particular plan sponsor’s pooled drug experience

    • The new insurer

      • Must pool its new clients’ high cost claims in its EP3 pool

      • Can exclude any drug claims that would normally be pooled by its EP3 pool if the drug claim was not covered by the pool of the previous insurer

      • Can exclude from its EP3 plan any pooled drug claim covered under the EP3 of the previous insurer that does not fit within the design parameters of the new plan


    Impact on advisors next steps and timelines2

    Impact on Advisors, Next Steps, and Timelines

    • At Industrial Alliance, current pools will stay the same

      • Standard $15,000 individual threshold for in Canada medical (drugs and non drugs)

      • Other thresholds possible

      • The Industry pool works like a reinsurance coverage for the insurer

    • Move to a per Certificate basis?

    • Three regions:

      • Pharmacare provinces

      • Quebec

      • Others  largest cost


    Impact on advisors next steps and timelines3

    Impact on Advisors, Next Steps, and Timelines

    • Canadian Drug Insurance Pooling Corporation established

      • Board is established

      • Searching for Executive Director

    • Insurers currently developing their EP3 offer and communicating with sponsors and advisors

    • Eligible group policies must be covered by an EP3 as of their first renewal date on or after January 1, 2013

    • Eligible drug claim payments to be pooled in the industry pool effective January 1, 2013


    Questions

    Questions?

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