Last year Aetna piloted a new product designed to lower the cost for health insurance small business plans. It’s called the Aetna Funding Advantage. The main idea is to circumvent large parts of the Affordable Care Act requirements. They can do this by managing a large group, and adding subgroups (employers) under this umbrella. With this in mind, this is only available for groups with 20 or more employees. This is a response to the growing demand for association health plans. These plans can be very tricky to enroll in and have many requirements to be eligible. A health insurance broker can provide you with some navigation to help complete the process.

Rates

Many ACA fees don’t apply to large groups. For example, the picori fee (minor) and other fees help determine the lower rates. The average saving for a client moving to this is 24%. That also tells me if a client isn’t saving at least 15% it’s probably not worth it. This is best for large groups and groups with lots of dependents. The rates come out in 4 tiers.

Qualifying

Aetna will deny coverage for groups based on poor health history
1-9 Employees: Not eligible
10-14 Employees: They require Health Statements (don’t bother)
15+ Employees: They are using GRX to underwrite (based on prescription drug use)
4 tier composite rates only
About 75% of the groups pass the health check. Of this group, about 50% move forward (according to Anna)

Surplus

If claims experience is better than expected they may receive a “Surplus” money back at the end of the year. Nationally 55% of groups enrolled received a surplus. The surplus is only refunded back to employers checking account, no other use. They only receive the surplus if they renew for the following year. Group receives 50% of surplus, Aetna keeps other 50%.

Network

Aetna Funding Advantage plans use Aetna‘s largest network. This INCLUDES the Mayo clinic (Aetna ACA compliant plans do not).

Benefits

These plans are not ACA compliant, they are ACA exempt.  If the plan name includes IntRx this means almost all benefits are subject to the deductible first.

Self-funded plans comply with federal health care reform and federal mental health parity mandates.

Aetna plans may provide coverage at the same or richer level than certain state fully insured mandates but are not subject to state benefit mandates.

Services that are not covered under SG AFA plans: acupuncture, artificial insemination/ovulation induction, advanced reproductive technology (ART), autism applied behavioral analysis, bariatric surgery, early intervention services, habilitation, hearing aids, modified foods (PKU/metabolic formulas ), non-emergency care in ER, non-urgent care in UC, pediatric dental, private duty nursing, specialist hearing exam, TMJ, vision hardware (adult/pediatric), RX lifestyle / infertility injectable drugs

Compliance

For small businesses, the insurance company issues employees 1095B forms at the end of the year. The main problem with a large group plan is the employer is responsible for this. With Aetna Funding Advantage, Aetna issues 1095B forms to employees.

Onboarding

They use their own benefit admin platform called Springboard. Aetna loads in invoices and claims experience reports for clients on the back end. This is the only place a bill is available for the group. In addition, new employee enrollments go through this system. Because of this, Every member needs an email address.

Payments

For Aetna Funding Advantage plans, all companies are on auto draft, no exceptions. They will auto draft on the month before the month of coverage. Aetna is not flexible with this date.

Extras

EAP program includes with 3 face to face meetings and unlimited telephonic meetings.
They will also pay for 4 classes per month to a gym. Orange theory is included as well as other alternative gyms (Crossfit, ect).
For a limited time everyone who signs up getting $224 towards an Apple watch, and spouses getting $199. See the flyer for the specifics.