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Claim Confusion

Posted on by Immix Group

Claim Confusion: Common Reasons Why Your Benefits Claim May Leave You "Out-of-Pocket"

Uncovering why you may be left ‘out-of-pocket’ when claiming under your benefits program

Wondering why you’re left ‘out-of-pocket’ despite having a robust benefits program? There is nothing more frustrating than submitting your claim, only to find it’s not covered, or not covered up to the level you expected.

Here are some common scenarios that explain why your reimbursement might fall short of your expectations.

Is it just the plan design?

Of course, benefits programs differ significantly from employer to employer. Often, the reason for a decline is simply the plan design selected by your employer. While a previous employer may have included certain items, your current employer may have opted to exclude the item.

Largely speaking, while insurance companies have varying default plan provisions, most can customize coverage to meet the employer’s preferences. For example, there is a broad range of paramedical practitioners that can be included, beyond the standard practitioners that most people expect to see. Less common practitioners such as Dieticians, Athletic Therapists, Kinesiologists, and Clinical Counsellors can often be included, but may not be standard for the provider.

While the blame is typically placed on the insurance carrier, more often than not, a decline has nothing to do with the carrier’s ability to cover something, but rather to do with the plan design implemented by the employer, based on a range of factors such as benchmarking information, budget, employee feedback, coverage availability for the industry etc. That said, there are many common rules and plan parameters, as outlined below, that are often the reason for a decline.


Is it the timing?

Many items have frequency limits attached to them, or a certain duration of time that must pass before you can claim the item again.

Understanding how the limits are applied is especially important. For example, does the benefit period apply to the calendar year (i.e. 2 calendar years apart), or at the 24-month mark from when the service was last claimed?


Routine Dental Visits  

The most commonly known frequency limitation is the ‘6-month recall’ often attached to routine dental visits. In short, this means that a routine exam and cleaning will only be covered every six months. If you book an exam too soon, your coverage will likely be declined. To clarify, if it is determined during a routine visit that you require follow-up procedures such as a filling, this does not mean you need to wait 6 months for the filling. It is only the routine exam that falls under the 6-month recall frequency limitation.

Some programs use a 9-month recall in order to help reduce costs. If this is not communicated, you may find yourself un-insured if your recall exam takes place too soon.


Vision Care Cycles

Vision care is commonly run on a 2-year or 24-month cycle, and the distinction is important. For example, your plan might provide vision care coverage defined as one of the following:

  • $200 per 24 months- this means you cannot make a second claim until 24 months from the date of the first claim.
  • $200 per 2 years- this means you could claim in 2022 and then again in 2024, even if your claims were as little as 13 months apart, so long as they fall two calendar years apart.

Frequency limits apply to many other common items including procedures for teeth, hearing aids, medical equipment, and medical supplies. Understanding and carefully reading the wording is important.


Does your coverage reset for the calendar year, or for the benefits year? 

While it’s becoming less common, some programs have their benefits reset to match the ‘benefits year’, which is often the anniversary date of the program, or the renewal date (and yes, these can be different!). This could be at any month of the year. This is in contrast to the benefits resetting for the calendar year, which is the more common plan structure.

For example, a plan may indicate a Benefits Year of May 1st– April 30th. If the program offers $500 per practitioner per benefits year, this means you will have the full amount available to you every May 1st.

The norm, and our preference, is to have benefits reset for the calendar year. This is easier for everyone to understand and aligns with the tax year.


Reasonable and customary limits

If you haven’t heard this phrase before, it’s simply the dollar amount of reimbursement that the insurance company will provide, for a particular item. These amounts adjust periodically, and they differ based on location and insurance carrier.

So, in contrast to naming a dollar value in the benefits booklet, it would indicate that the R&C limit applies:

  • Eye Exams once per year to $100 vs.
  • Eye Exams once per year to R&C limit

Often, the R&C limit is higher than a defined dollar limit. When a program has not been updated in a long time, the defined dollar limit can become very outdated and not representative of the average cost of the service in the area. The choice the employer makes in this regard has an impact; implementing fixed dollar amounts can assist in containing claim costs. 

Charging above the dental fee guides

Here’s the scenario: you have 100% basic dental insurance. You go for a regular cleaning, and nothing unusual occurs. When the dental office submits your claim to your insurance provider, you owe a portion of the total. Why would this be? Why is 100% not actually 100%?

In short, most insurance carriers reimburse based on the current dental fee guide in your province of residence. Dental offices, however, can charge beyond these guidelines. 

Did you know?

You can address out-of-pocket expenses effectively with a Health Spending Account (HSA). Many individuals wonder if HSAs can be used to cover uninsured expenses or supplement coverage for partially covered or capped items and the answer is yes!

Learn how a Health Spending Account can enhance your benefits program and provide additional financial support where needed.

In higher-cost areas, this is particularly common (downtown Vancouver or Toronto, for example). So, when the insurer reimburses at 100%, the fine print is that they reimburse 100% of the applicable provincial fee guide.

In some instances, a plan will provide a percentage in excess of the fee guide or will allow for excess reimbursement for specialists (i.e. Endodontist, Periodontist). Again, this differs from carrier to carrier.  

Dental fee guides adjust each year. As we have written about and discussed with our clients extensively, 2022 and 2023 saw much higher than usual increases, whereas 2024 saw a return to more moderate adjustments.

 

Claiming under two plans

Remember earlier when we discussed R&C limits? Well, this comes into play when you are claiming under two plans.

If you are covered under two plans, you claim through your own employer-sponsored plan first, then claim second under your spouse’s plan for any unpaid balance. Many people assume that the result should be $0 left out-of-pocket. However, this is not always the case.

Consider this scenario: You go for a physiotherapy visit, the charge is $160, and you claim under your employer’s plan. In your province with your provider, the Reasonable & Customary limit is $120, which is paid out. This leaves you $40 out-of-pocket.

You then claim the $40 to your spouse’s plan, which covers $0 of the remainder. But why? The reason is that the second provider has an R&C limit that is equal to or lower than your own plan’s limit. The plans have coordinated to the R&C limit.

Unfortunately, having two plans does not always mean you will be reimbursed for a higher dollar amount than under one plan.

Please note: R&C limits can differ quite significantly between carriers and by location; for example, with Manulife Financial, the R&C for physiotherapy ranges from $80 (PEI) to $165 (NWT and Nvt) for a regular visit.

 

Outdated, but standard, coverage limits

Within a program, there are certain extended health care items that have a defined dollar limit of reimbursement, in contrast to others, which do not (i.e. the full cost is covered, at the coinsurance of the program).

These defined dollar limits tend to be quite similar, carrier to carrier. Unfortunately, reimbursement falls short of the actual cost of an item, simply because the industry standard has not kept pace with the actual retail cost of the item. Two examples are:

  • Eyeglasses (especially progressive lenses); while Vision Care amounts can be customized by the Employer, it’s quite common to see $200 per 24 months, which is below the typical cost for certain glasses.
  • Hearing Aids; notably, hearing aid coverage is often at $500 per 5 years, which is far below the typical retail cost for hearing aids which can be thousands of dollars.

In these instances, the employer can request for these plan provisions to be increased beyond the standard insurer provisions. However, these increased coverage limits typically come with a cost.

 

Errors happen, by providers and members

Quite simply, people make mistakes. Most of the time, when we dig into a denied claim, we learn that the provider or member has made an error when entering the claim. A common issue is claiming for the wrong practitioner (i.e. Acupressure instead of Acupuncture), claiming for the wrong duration of the visit (i.e. a physio receipt says subsequent visit and the member claims for initial visit), or simply keying in the wrong numbers from the member ID card.

In one instance, a claim was repeatedly denied, and we learned the child had been entered by the pharmacist as ‘male’ rather than ‘female’ and the system was therefore not aligning the enrolled dependent to the claimant. A simple error, but frustrating nonetheless for the member standing at the pharmacy watching the claim get repeatedly denied!

Periodically, we come across a denied claim for a very uncommon item (often, a medication). In many instances, the item is simply not coded into the insurer’s system, and with a special request, we can often have the item included.

 

Understanding the details, matters

As we have outlined, there are many reasons why your extended health or dental claim may be unexpectedly denied or cut back.

We know that the number one indicator of employee satisfaction with a benefits plan is smooth and understandable claims reimbursement. Denied claims are frustrating and at the Immix Group, we want our clients to reach out to us when they encounter issues with their claims.

Even better, proactively, our goal with our clients is to ensure they understand the structure of their plan, and the various rules and procedures surrounding claims.

Employee education sessions where members can delve into the details of their program and ask questions are very useful and can prevent unneeded frustration for members.

At the Immix Group, we are here to help you make the most of your benefits program and ensure a smooth claims experience.

If you encounter issues with claims or need assistance understanding your coverage, don’t hesitate to reach out at info@immixgroup.ca or (604) 688-5559 – we love to hear from you! 

Key Takeaways

  • Many benefits claims are denied because of the plan design implemented by the employer- they may have chosen not to cover certain items or have implemented specific timelines for cost-saving purposes. It’s important to be aware of these limitations to avoid unexpected out-of-pocket expenses.
  • If in doubt, always ensure you obtain pre-approval for any benefits services or items before proceeding with treatment. Pre-approval helps prevent claim denials and ensures you understand what is covered under your plan.
  • Familiarize yourself with any timing limitations in place for your plan. For example, some services may have frequency limitations or waiting periods between claims. If you’re unsure about any details, reach out to your benefits provider for clarification.
  • Understand the Reasonable & Customary (R&C) limits for services covered under your plan. These limits determine the maximum amount your insurer will reimburse for specific services and usually differ by region.
  • Check with your dentist to understand how they bill for services. Some dentists may charge in excess of fee guides, which could impact your out-of-pocket costs depending on your benefits coverage.
  • Navigating benefits claims can be complex, but understanding the ins and outs of your benefits program is essential for maximizing coverage and minimizing out-of-pocket expenses. Take proactive steps to educate yourself about your benefits plan—review your plan documents, ask questions, and seek clarification from your benefits provider or advisor.

FAQ

Longer durations, such as a 9-month dental recall, are often implemented as a cost containment strategy to reduce claims expenditures within a 12-month period, thereby helping to manage overall program costs.

You or your healthcare practitioner can submit a request for pre-approval. This process is common for dental procedures and other more costly healthcare services, ensuring clarity on coverage and reimbursement amounts before proceeding with treatment.

Not necessarily. While flexibility in coverage can increase with larger employers, insurers must work within provincial health coverage guidelines and adhere to CRA rules/Canadian tax laws. Underwriters may also limit plan designs to avoid excessive claims that could jeopardize the financial stability of the program.

For instance, a smaller group might not have the capacity to offer non-standard coverage like 80% coverage for Major Dental services with an unlimited annual limit. The financial risk associated with such extensive coverage could be prohibitive, especially considering that non-refund insured plans can be terminated without any deficit obligations.

Refer to your benefits booklet or contact your benefits administrator for a detailed list of covered services and items. As well, details are generally available online or through your providers mobile app. Understanding your plan’s coverage terms will help you make informed decisions about healthcare expenses.

Pre-existing condition limitations may apply to certain health conditions that existed before your benefits coverage started. These limitations can impact coverage eligibility for related treatments or services; this is more typically applicable for disability claims or travel claims.

Reasonable and customary charges apply to practitioner services such as these. Coverage for practitioners varies by province and provider and are generally updated annually. Check your benefits booklet or contact your benefits provider to confirm eligibility and coverage details for these services.

  1. If your claim is denied, request an explanation from your benefits provider (an EOB or Explanation of Benefits is usually produced automatically). Sometimes, claims are denied due to incomplete information or misunderstandings. Your benefits advisor can assist in resolving claim issues.

Yes, coordination of benefits (COB) allows you to maximize coverage if you are covered under more than one insurance plan. You’ll first send the claim to the plan you are a member of (primary coverage) for adjudication and payment. Then you can submit any eligible outstanding amount to your other (secondary) coverage. Coordinate with both insurers to ensure you receive the maximum allowable reimbursement for eligible expenses.

Further Reading

Key Conversations in Benefits 2023

Health Spending Accounts

One size fits all? Not when it comes to employee benefits.

Dental Fee Increases for 2024

 

Lindsay Byrka

Lindsay Byrka BA, BEd, CFP

Vice President, Immix Group: An Employee Benefits Company
A Suite 450 – 888 Dunsmuir St. Vancouver V6C 3K4
O 604-688-5262 E lindsay@immixgroup.ca
W www.immixgroup.ca

Three Reasons to Implement a Group Savings Plan

Posted on by Immix Group

We write often about Group Savings Plans, as it’s our belief that one of the best ways employers can assist their employees is by offering them the opportunity to plan and save for the future.

This is a sentiment that is echoed by many in our industry. In their recent 2023 recap, iA’s Director of Plan Member Wellness and Education stated the need to evolve our thinking when it comes to group savings programs, and more specifically, to “develop engagement strategies that focus on supporting people to achieve their personal goals.”

Our interpretation of this comment is that your purpose in setting up a Group Savings Plan should extend beyond simply finding a way to provide more funds to your team, or setting up a plan just because you need to be competitive with similar employers. Employees are self-reporting that they are feeling significant stress, and the number one reason is due to finances. It goes without saying that everyone has many and varied personal goals related to achieving financial peace of mind.

The three reasons to implement a group savings plan we are focusing on here focus on these facts: the support is needed, the tactic is effective, and implementation is simple.

 

 

1. Employees need support when it comes to financial literacy training and tactics to get them on track in this area of their lives

 

As we wrote about previously, a Group Savings Plan targets a key stressor for employees- their finances. The stats are clear, as reported via the 2023 Benefits Canada survey as well as through the Financial Consumer Agency of Canada:

  • 32% of Canadians report feeling a high level of anxiety, stress, or worry over money.
  • Only 49% of Canadians describe themselves as financially knowledgeable.
  • 36% feel they are just getting by, financially speaking.
  • 67% of Canadians said their debt increased by more than $5,000 in the past 12 months.
  • 53% have an emergency fund (2023), down from 64% in 2019.

As the image from the Benefits Canada Survey shows, “Personal Finances” continues to rank #1, followed by Workload and Work-Life Balance.

Screenshot 2024 02 29 at 10.04.40 PM

The answer is not simply to ‘pay people more’. Equipping people with the ability to save in a systematic and tax-effective manner, and contributing to these savings through an Employer match goes a long way. Additionally, and most importantly, Group Savings Programs provide employees access to education resources, planning tools, and financial advisors that they may otherwise not bother to seek out. Access to financial advisors to help employees achieve their personal financial goals, even if it’s as simple as developing a budget to assist with living within one’s means, can create a lasting impact and potentially redirect the trajectory of one’s financial future.

Simply put, a Group Savings Program is an opportunity to assist your employees where they need it most.

 

2. It provides an immediate, twofold beneficial impact as savings grow and taxes are reduced

 

Contributions to an RRSP (Registered Retirement Savings Plan) reduce taxable income. The difference with a Group Savings Plan is that contributions are made directly via payroll deductions.  When employees contribute to an RRSP directly from their paycheque, they experience income tax savings in real-time, as they are taxed on their after-contribution income.

We mentioned earlier the perspective that employers should seek strategies to assist employees in reaching their personal goals. Many employees identify financial goals, and particularly the development of a retirement savings account, as incredibly important.

Over time, and with engagement with the many planning tools available, an employer-sponsored program assists in creating a sense of achievement and tangible progress as retirement savings grow.

An added bonus? The Employer contribution. While not mandatory, this of course serves to boost an employee’s account value, taking them more quickly towards their goal.

 

3. Simple, low touch, high ROI

 

Lastly, it cannot be overstated how simple it can be to implement and manage a group savings plan. In contrast to the requirements of a pension plan, a simple group RRSP or group RRSP-DPSP combination plan is very low touch from an administrative perspective.

Even a very small employer can easily implement a Group Savings Plan that provides similar access to all the features (online platform, resources, investment funds, planning tools, etc.) that a much larger employer offer. It’s a way to recruit, retain, and remain competitive. In short, implementing a group savings plan provides a great return on investment.

Already have a group savings plan in place? Here are a few checkups:

  • Have you taken advantage of our offer to host an education seminar?
  • When was the last time you assessed the contribution level made by the Employer? Has it kept pace with inflation?
  • When was the last time you reviewed Employee contribution levels? Have employees been reminded that they can increase their payroll deductions, again, to keep pace with inflation or changing circumstances?
  • When did you last run an audit of participation levels? Is everyone who is eligible to participate enrolled?
  • Are you aware of and communicating the many comprehensive resources available through your provider and advisor?
 

Help employees to save for the future

 

In summary, implementing a Group Savings Plan is a direct response to the financial stress reported by employees. Beyond immediate benefits like tax-effective contributions and employer matches, it offers a straightforward and high-return solution to recruit, retain, and stay competitive. By addressing employees’ financial concerns holistically, it not only eases stress but also fosters financial growth and supports personal goals.

At the Immix Group, we recognize the importance of financial literacy which is why we offer lunch and learn seminars where we explain, simplify, and guide our clients through their programs to help them maximize their benefits. Additionally, our clients have direct access to our sister company, Ciccone McKay Financial Group, where dedicated advisors are available and ready to provide personalized assistance.

It’s desired, it’s beneficial, and it’s simple to implement and administer! If it’s been on your mind to look into a plan for your employees, we’re happy to help you discuss options.

FAQ

Beyond just funding your team or competing with other employers, it addresses the top stressor reported by employees—financial concerns.

By enabling systematic savings and offering tax-effective contributions, it directly tackles the rising anxiety and lack of financial knowledge reported by Canadians. It also provides employees access to education resources, planning tools, and financial advisors that they may otherwise not bother to seek out.

It offers real-time income tax savings as contributions are made directly from paycheques, creating tangible progress toward personal financial goals.

While not mandatory, this of course serves to boost an employee’s account value, taking them more quickly towards their goal.

It’s simple, low-touch, and offers a high return on investment, making it easy for employers to implement and manage.

It requires minimal administrative effort, making it accessible even for small employers to provide features similar to larger employers.

Implementing a Group Savings Plan enhances competitiveness, contributing to employee satisfaction and loyalty.

Regularly assess Employer and Employee contributions, participation levels, and leverage available resources for ongoing plan success.

Further Reading

Add to your Recruitment and Retention Toolkit with a Group Savings Plan – Latest News from Immix Group

3 Action Steps Employers Can Take to Reduce Employee Financial Stress and Increase Financial Literacy – Latest News from Immix Group

Business Owners: How to Design the Best Group Savings Plan for your Company

This might just be the right time for you to implement an employee group savings plan – here’s why and how

Canadians’ Financial Well-being: Summary of FCAC survey findings – Canada.ca

Report | Benefits Canada.com

Top Benefits Conversations of 2022

Posted on by Immix Group

It’s a wrap! As we begin the New Year with refreshed energy and excitement for what 2023 may bring, we wanted to share a recap of the key stories in benefits over 2022.

 

Extreme Difficulty in Hiring

The theme of our client meetings this year can be summed up in one simple sentence “Where did all the people go?” Businesses struggled to hire (and retain) qualified people. Employers told us they had candidates ‘ghosting’ interviews or simply not showing up to their first day, a trend that most had never previously experienced.

Time and again we were told by employers that they were desperately in need of staff, and that their existing team members were stretched too thin or in roles they were not hired or properly qualified to fill. The labour shortage is evident with a record-tight labour market, according Stats Canada: Labour shortage trends in Canada (statcan.gc.ca).

“Salary and benefits” continue to top the list of most important job factors for employees. Providing and more importantly communicating and highlighting a competitive benefits offering will make you stand out.

top benefits2

The Shift to Hybrid Work

There has been a massive shift in how we work over the past few years. Hybrid work, or working partly remote and partly in-office became the norm post-pandemic, with most employees reporting they prefer working from home.

This has had a big impact in terms of managing and hiring, measuring performance, and ensuring engagement. We wrote about hybrid work and posed the question: Is working from home an employee benefit in two parts. The basic takeaways are that remote work is here to stay, employees prefer a hybrid model, and a formalized WFH policy is a must. 

 

The Great Resignation, or rather, the Great Retirement

The much-discussed Great Resignation did not occur in Canada like it did in the US, but what Canada experienced is actually more concerning:  a record number of retirements.

A record 300K people retired in Canada in the 12 months up to July 2022 (up 30% from the same period the previous year). Early retirement, so those between age 55-65, made up almost half of the overall number of retirees. With our demographics here in Canada, it will only grow larger. With the most experienced people exiting the workforce, there is a real risk to businesses due to the lack of mentorship and transfer of knowledge for younger generations.

How does this tie into benefits? Offering those in the final stages of their career enhanced coverage and work flexibility are potential solutions to entice your most experienced people to stay a few additional years.

 

Continued Focus on Mental Health and Well-being

As we transitioned out of the pandemic, the focus on mental health remained at the forefront. Employers continued to ask for resources and coverage options to ensure their staff had access to the mental health support they required.  

Far beyond the EAP or the dollars available for counselling visits, employers sought various ideas to support mental health including: return to work plans, 4-day work weeks, assisting employees with financial concerns through financial literacy and group savings plans and other programs designed to provide the flexibility needed to better support individuals and families and remove barriers to care.

More than one third of all 2022 Long Term Disability claims are mental health related. Claims for mental health are up 75% from 2019, and experts anticipate this will rise in 2023.

 

High Inflation

A key conversation in 2022 was the inflation we saw across the board; this was especially noticed with the cost of groceries. After years of low interest rates, Canada experienced eight interest rate adjustments in 2022. For many people, this directly impacted their borrowing costs, affecting both personal and business expenses and decisions.

2022 saw increases to the Dental fee guides far higher than historical averages. Unfortunately, it appears that the Dental Fee Guide increases for 2023 will once again be much higher than usual, with 8.5% for Ontario and 9.8% for Quebec already reported. With costs for practitioners and other insured expenses also rising, we anticipate larger than typical increases to claims across plans.

 

Federal Dental Plan

The Federal Dental Plan was rolled out the end of 2022. Employers had many questions on this program, wondering the impact to their Employer-sponsored insured dental plans. Generally speaking, there is little or no impact on existing plans, due to the qualification parameters for the new Federal plan.

The program provides coverage for children under 12 only. In order to qualify for any level of coverage, family income must be under $90K, and the children must not have access to private dental coverage (i.e. Employer plans). The government states that this is the first stage in developing a more comprehensive federal dental plan; only time will tell!

 

Change to EI Sickness Benefits

Effective for December 18th, 2022, the Federal Government announced a change to EI Sickness benefits, extending the duration of pay from 15 weeks to 26 weeks. Employers had many questions about this and the impact on their insured Long Term Disability programs which typically begin at week 17, at the expiration of EI Sickness payments.

In short, Employers are not required to adjust their LTD plans. Generally speaking, it is not in the best interest of those who are insured under LTD plans to remain on EI Sickness rather than transitioning to LTD. 

top benefits3

Flexibility in Benefits

 
Finishing up the list, an underlying theme to benefits conversations in 2022 was the desire for flexibility and customization. As we know, one size does not fit all when it comes to benefit plans, which these days must include elements of flexibility to ensure everyone’s needs are met. We saw employers embracing customized work arrangements including hybrid work models and four-day work weeks.

From a product standpoint, the Immix Group set up more Health & Wellness Spending Accounts than ever before as Employers sought a simple way to provide spending flexibility to their team.

As always, we are happy to discuss your program with you!

Please reach out to us to discuss how we can help with your program; we love to hear from you.

 

Read more:

 

Labour Shortage Stats Can:

https://www.statcan.gc.ca/en/subjects-start/labour_/labour-shortage-trends-canada

 

Retirement:

https://www.theglobeandmail.com/business/commentary/article-the-great-resignation-has-arrived-in-canada/

https://thehub.ca/2022-09-20/trevor-tombe-canadas-not-so-great-resignation-its-retirements-we-should-really-be-worried-about/

https://www.benefitscanada.com/benefits/health-wellness/how-can-employers-turn-the-great-resignation-tide/

 

Hybrid Work:

https://www.benefitscanada.com/news/bencan/survey-finds-78-of-canadian-employees-prefer-working-from-home/

https://www.benefitscanada.com/news/bencan/61-of-canadian-employers-using-hybrid-work-model-survey/

https://immixgroup.ca/blog/index.php/2022/03/23/the-hybrid-work-model-is-working-from-home-an-employee-benefit-2022/

https://immixgroup.ca/blog/index.php/2022/04/19/part-2-the-hybrid-work-model-is-working-from-home-an-employee-benefit/

 

Inflation:

https://www150.statcan.gc.ca/n1/en/catalogue/62F0014M2022014

https://www.sunlife.ca/workplace/en/group-benefits/focus-updates/over-50-employees/provincial-dental-fee-increases-for-2022/

8 Reasons for Increases to your Employee Benefit Plan Premiums    – Latest News from Immix Group

 

Mental Health:

More than a third of disability claims in 2022 due to mental-health reasons: survey | Benefits Canada.com

Mental health claims soar by 75 per cent | Canadian HR Reporter

https://www.benefitscanada.com/benefits/health-wellness/hybrid-work-four-day-workweek-shaping-employee-well-being-expert/

https://www.benefitscanada.com/benefits/health-wellness/2022-healthy-outcomes-conference-centering-employee-well-being-in-return-to-office-plans/

 

Flexibility in Benefits:

One size fits all? Not when it comes to employee benefits. – Latest News from Immix Group

Lindsay Byrka

Lindsay Byrka BA, BEd, CFP

Vice President, Immix Group: An Employee Benefits Company
A Suite 450 – 888 Dunsmuir St. Vancouver V6C 3K4
O 604-688-5262 E lindsay@immixgroup.ca
W www.immixgroup.ca

One size fits all? Not when it comes to employee benefits.

Posted on by Immix Group

Yes, it’s possible to gain the pricing advantage found within a benefits pool while also having control over your plan design!

When we begin discussing the strategy that Immix has created when it comes to group benefit plans one of the first questions we are asked is whether belonging to a benefits pool means having to implement a specific benefits plan design for your company. The short answer? Absolutely not! We know that one size does not fit all. The needs and wants of an organization when it comes to benefits vary dramatically, and our role includes not only ensuring you’re able to implement exactly what you want, it’s helping you to design the right program.

 

 

Standard plan designs don’t make sense- because every business is different.

Businesses view their benefit plans differently, and the structure and offerings of the programs reflect this. There is no real ‘right or wrong’ but there is effective and ineffective at reaching your desired outcomes.

Ensuring your benefits plan fits into your overall compensation model, matches your business’ philosophy and values, and does what it’s intended to do is not simple! This is where experienced advisors play a huge role. We know the market, we know how to design cost effective strategies, and we can help you achieve your goals.

 

 

But you know your people best

You probably have a good gut instinct as to the needs of the people that comprise your organization, especially if you’re a smaller team. You likely have demographic data on the age and sex breakdown of your group as well. But the key word here is ‘people’! It’s easy to get caught up in making assumptions based on the demographic profile of an organization.

And yes, there are many generations in the workplace today and there are certain characteristics we tend to assign to different generations. Generations in the workplace is one thing, but people are still people. Just because you’re 25, doesn’t mean you don’t have a chronic illness.  And just because you’re 65, doesn’t mean you don’t want a wellness spending account to cover your gym memberships and supplements.

While we tend to focus on age groups when we’re discussing benefits, we want to acknowledge that as individuals, we have vastly different needs, regardless of where we fall in the generational tagging system. There are also geographic and industry differences that affect what the benefits plan offering should look like. Understanding exactly who your people are is the key to designing just the right program.

 

A little data goes a long way

Knowing your people is one thing, but translating this into the correct scope for your benefits offering is something else. This is where the team at Immix Group comes in; you might need our help to survey your staff, to analyze your historical claims experience, or to walk you through programs and services that may be new to you. If you’re like a lot of employers, you might be seeking to add flexibility and choice to your benefits offering. The good news is that this is now easy to achieve!

beyond traditional health benefits

Because the right program makes a difference

The phrase ‘recruit and retain’ gets tossed around a lot when it comes to discussing the purpose of a great benefits plan. To break it down, you want the right benefits to help keep your best people. Salary compensation is important too, but what your organization brings to the table that adds to the total compensation package could be enough of a difference-maker to keep your best staff over the long term. The same applies when you’re recruiting; recruiting is challenging, and more and more people are asking up front about benefits offerings.  

Benefits beyond a traditional health and dental plan

A shift we have seen is towards asking about non-traditional benefits (so beyond the typical health insurance/ dental plan). Potential hires are asking about things such as health spending accounts, wellness/lifestyle spending accounts, group savings plans or a virtual care/mental health support program (or all of this!). People want the details on paid parental leave and paid time off, which goes hand in hand with the focus on work-life balance, and organizational flexibility as a whole.
employee benefits life balance

We designed our pools with flexibility and customization in mind

 One of the key benefits of how we have structured our broker-managed pools is that they actually have the reverse effect of a typical pool; we are able to provide MORE flexibility, including a choice from multiple major carriers.

Because we are working with our insurance carrier partners in a unique way, we are not always subject to the typical constraints imposed by underwriters for small groups (limits on life insurance, limits on dental coverage for new groups, limits on paramedical amounts). Our partners consider you part of our overall block of business, rather than treating you as a stand-alone company. While you’ll always be able to see your own claims experience and dollars in and out of the plan, being viewed as part of the Immix ‘block’ behind the scenes provides you with more than just pricing advantages.

 

Benefit plans must be cost effective

Even a fully customized, flexible benefits plan can be cost effective. The pricing model we’ve created at Immix is ideal for achieving the balance between customization and the low admin fees associated with inclusion in a pricing pool. Because we are negotiating the overall admin costs with the insurance provider on behalf of a large number of businesses, we’re able to pass the savings along to you, and spend the time needed to get the plan right- rather than haggling over pricing with the insurer on a group-by-group basis.

 

Not all pools are created alike

We understand that when you hear the term ‘pool’ you may jump to the conclusion that your business will be forced to implement a standard plan design or choose from a few plan options. Or, that you won’t be able to see any of the claims experience for your group. While other benefit pool offerings do take this approach, this is simply not the case with the Immix Pools.

Customization does not need to be expensive or complicated. Offering benefits that meet the needs of your employees regardless of age, sex, health or other identifying criteria can be done, and on your budget.

That’s why our model is so effective; low administrative costs, total customization and transparency, and experienced advisors who can work with you in a dedicated way to get it right.

Please reach out to us to discuss how we can help with your program; we love to hear from you.

Lindsay Byrka

Lindsay Byrka BA, BEd, CFP

Vice President, Immix Group: An Employee Benefits Company
A Suite 450 – 888 Dunsmuir St. Vancouver V6C 3K4
O 604-688-5262 E lindsay@immixgroup.ca
W www.immixgroup.ca

Check to Ensure your Benefits Quote is Actually for a Comparable Plan

Posted on by Immix Group

5 Key Areas to Check to Ensure your Benefits Quote is Actually for a Comparable Plan

Inflation is on everyone’s mind; wherever you look, prices are rising. Unfortunately, benefit plans are not exempt from this. When the cost of dentist visits, medical items and procedures goes up, the result is often higher claims. This can sometimes end up passed along to employers as a renewal rate increase. 

Many of you may be considering getting a quote on your benefits plan or may have already received quotes from alternative providers.  Before you make a decision on moving your program, there are a few key points to check to ensure your quote is not too good to be true.

Is it truly apples-to apples?

Consider this scenario: you’ve been presented with a quote for a benefits plan. You had asked for the quote to be apples-to-apples to your current plan. The good news is the price is significantly cheaper than what you’re paying, and supposedly, the plan designs are equal. But are they?

In our line of work, it’s not uncommon to come across what is positioned as a comparable plan, only to find there are many details that have resulted in the lower price. They can be glossed over in a plan summary, and when the time is not taken to examine every nuance to the coverage, it can leave owners- and their employees- disappointed. There is nothing worse than rolling out a new program only to hear from an employee that their prescription -which was always covered under the old plan- is now excluded.

As we have written about in the past, it’s very common to get discounted pricing from an insurer. In short, the carriers usually need to extend some level of reduced pricing in order to gain your business.

And certainly, there are opportunities for true savings on administration costs.  But discounts aside, and beyond the summary of the coverage, we have compiled a list of specific plan elements to check and compare. 

 

Top 5 things to Review if a Benefits Quote seems Too Good to be True

 

  1. Review the details of the Prescription Drug Plan:

What are the details of the drug plan? Is there a managed drug formulary, excluded drug categories or drug caps? Does the plan mandate generic substitution or not?

A drug formulary is simply a list of the drugs that are covered on the plan. Oftentimes, a drug formulary is designed to exclude certain medication categories (fertility drugs or oral contraceptives are typical examples), in order to cut costs. In some instances, a drug plan may even exclude specialty drugs, the expensive but often lifesaving/ lifestyle saving drugs. While it’s often positioned as a benefit to employers, this could leave your employees with major uncovered drug expenses.

It is important to understand the implications of the drug plan. Generally speaking, a drug plan is a key part of the extended healthcare and is intended be an insurance plan. A plan that covers antibiotics (roughly $10-15) but excludes drugs for MS or Chrohn’s disease ($10K+ per year) is not providing coverage against a financially significant, often unexpected expense. While it’s true that a more open drug plan could mean higher drug claims than under a more restricted, managed formulary, the program’s stop-loss max will typically work to limit the plans exposure to high-cost drugs.

How the program adjudicates brand name versus generic drugs should also be clearly known; it’s standard these days to have generic substitution on a program, but this can work differently depending on the carrier or how the plan is set up (for example, will the plan allow the doctor to indicate ‘no substitution’ and therefore cover the brand name version of a drug?). Differences in this area have cost implications.

Lastly, is the annual limit for prescription drugs ‘unlimited’ or is there a dollar limit? You may be okay with implementing a capped drug plan, but again, you need to understand the details and implications. A qualified and experienced benefits advisor will be knowledgeable on all the above points, and most importantly, should be open and transparent about what you are getting.

Reviewing the health benefits plan
  1. Check the Dollar Maximums and Limits for Key Items:

You may have checked in the plan summary that the coinsurance is the same; 80% on certain lines of coverage, 100% on others. But what are the per item or category maximums?

 

The following are the most common items where benefit maximums may be listed, in the fine print:

      • per visit limit for paramedical services, such as $10 or $25 per visit reimbursement, rather than up to the practitioners reasonable and customary limits (i.e. $100 for massage visit)
      • annual per person dental limits in dollars; is this per level of coverage, or combined?
      • dental procedure limits such as scaling units
      • dental recall limits; is it the standard 6 months or has it been pushed to 9 months or even 12?   
      • eye exam limits; is it set to “reasonable & customary” meaning it will adjust with inflation, or is it a set amount? Is the amount reasonable given the cost in your area?
      • Orthotics, surgical stockings and other medical items
      • and as mentioned, is there an annual drug maximum, vs an ‘unlimited’ drug plan

 

While item reimbursement limits are standard practice, they do vary by carrier and many can be customized in a quote. It is important to understand how this may compare to your current plan, and whether the limits are reasonable, given the overall cost of the item, and the intent of your program.

 

 

  1. Check the Contract Wording and Coverage Details of the Disability Insurance

 

We say it all the time: long term disability coverage is the most important but often the most overlooked part of a benefits plan. This is an area to pay close attention to; in the event of a claim, how the claim is handled depends on the contract that is in place which could greatly impact the plan member, potentially for decades. Things to watch for:

      • What is the definition of disability, in words? How does this compare to your current plan?
      • Are commissions, bonuses and overtime pay or T5 earnings properly addressed? If the contract covers salary only, and this is a small percentage of total compensation for certain people, that could leave them grossly underinsured.
      • Cost of Living Adjustment; is there a COLA clause, or an inflationary adjustment included for the benefits payments? Is this important to you?
      • Is the program set up as taxable or non-taxable (is the employer or the employee paying the premiums?)
      • Is the duration of disability benefits to age 65? While this is the norm, we are seeing a trend towards a 5 or even 2 year benefit duration, to reduce costs. If someone goes on disability, they could be disabled for the duration of their life; an insurance plan that only pays them for a few years may not meet your requirements as an employer.

 

There is no bigger waste of money and potential liability than a disability plan that fails to cover people adequately and accurately; reviewing this area with an expert is crucial.

Reviewing details of a health benefits quote
  1. Check the Termination Ages: How long can people remain on various parts of the plan?

Different benefit lines typically have age-based termination or reduction schedules. For example, many life insurance benefits reduce the coverage by 50% at age 65, and then terminate completely at age 70 or 75. For health and dental, coverage is often in place right to age 75 or even ‘retirement’, meaning there is no actual termination age so long as someone is still actively at work.

We have noticed a trend towards lowering termination age and have seen coverage ending at 65 or even 60! For many employers, this is a big deal and it’s often not highlighted in a summary of benefits as a deviation. It is a good idea to additionally check the travel coverage and ensure this part of the extended health care is retained in alignment with the EHC, if possible.      

  1. Review the Mechanics of the Pricing:

Many people fail to review how the quoted premiums compare to the historical claims, or to do a basic ‘reality check’ on a too-good-to-be-true quote. On a typical experience-rated program, the premiums must be adequate to pay the claims, with the other pricing factors such as inflation, IBNR and target loss ratio taken into account.

Some questions to ask are: What is the actual discount that the carrier is investing? What is the duration of the rate guarantee?  What will be the process (financially speaking) when the plan is renewed? What is the Target Loss Ratio? If the plan is to be part of a pool, how does it work? Many times, you can find this out and often the carrier will be transparent as to how they plan to recoup any losses. A qualified benefits advisor should be able to explain this in detail and understand exactly what the renewal process will look like with a specific provider.  

 

Some plan design differences may be acceptable to you

There are always going to be nuances to carriers that are unique to them, and where they simply won’t directly align with your existing plan. Sometimes this means a slight improvement, and sometimes this could be perceived as a takeaway. At the end of the day, what’s important is that you understand the small deviations and that you are not buying something under misleading or mistaken circumstances.

An experience and qualified benefits advisor will do a detailed analysis

With the help of an experienced benefits advisor who knows the terminology and nuances to a quote and contract, the details can be understood. You may review any differences and be totally fine with the program not providing the same level of coverage. The key is to be aware, understand any implications, make an informed decision, and communicate any changes to your staff.

At the Immix Group, our benefits experts can help you obtain a quote, understand the quote and what it means for the future, and manage not only the onboarding of your new program, but the ongoing plan management. 

As always, feel free to reach out to us. We love to hear from you!  

Lindsay Byrka

Lindsay Byrka BA, BEd, CFP

Vice President, Immix Group: An Employee Benefits Company
A Suite 450 – 888 Dunsmuir St. Vancouver V6C 3K4
O 604-688-5262 E lindsay@immixgroup.ca
W www.immixgroup.ca

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Part 2: The Hybrid Work Model: Is working from home an “employee benefit?

Posted on by Immix Group

In the first part of this two-part article on the hybrid work model, we discussed remote work from a productivity perspective. For the most part, the numerous studies that are coming out are stating that productivity is either unaffected or increased, and this is especially true for knowledge workers.
In addition, most employees prefer working from home, or at least having this option part of the time. We will now take a closer look from an HR perspective as to why maintaining or implementing a permanent hybrid work model may be the smartest choice for your organization. We will seek to answer:

 

What do employees want? Do they prefer a Hybrid Work Model?

Yes, the stats are clear. The majority of employees want the option to work remotely, at least part of the time, and they feel very strongly about this! Some survey results show:

  • 76% said support for flexible work post-pandemic is important to them
  • 62% want to work from home at least 40% of the time
  • 30% want to work remote at least 3 days per week.
  • 27% of Canadian office workers would prefer to be fully remote

In fact, just 12% said that working entirely from the physical workplace would be most ideal. While many employees missed the social connections and other benefits of being in the workplace, the benefits of hybrid work far outweigh the in-office advantages.
As quoted in the HR Reporter: 

It’s clear that the role that the physical office plays in the day-to-day work and satisfaction of employees has changed dramatically during the pandemic. We’re not going back to how things were before, and businesses need to adjust to the many operational realities that come with that,” says Nick Georgijev, country manager for Amazon Business Canada.


Why do employees prefer remote work? What does remote work offer?

Turns out that positive workplace culture is much more than ping pong tables and endless snacks, which don’t actually provide employees with key things they really want to feel valued, which include flexibility, work-life well-being and autonomy. Among other benefits, working from home at least part of the time offers:

  • Reduced costs in commuting; transit and vehicle maintenance
  • Time gains, including from lack of commute 
  • Location flexibility, such as the ability to live in a lower cost area
  • Flexible working hours
  • Customizable office spaces and the comforts of home
  • Mental health benefits and general improved well-being
  • Increased productivity for many
  • Overall healthier people, according to studies on long-term hybrid workers

 

To expand on a few of these points, for many, the ability to work from home is a key part of improved work-life well-being. Flexibility as to where one works can be an integral piece in achieving a balance that minimizes work related stress while optimizing health and general well-being.

For example, for those with young kids, working from home instead of commuting to a physical workplace can mean many extra hours spent with young children, per day. It can mean easily integrating simple household tasks, rather than being absent from the home for eight or ten hours or more.

Many of the benefits are both financial and reduce stress: reduced or no commute, less time and money spent on office apparel and physical appearance, and the potentially most significant, housing. When it comes to housing, being able to work remotely could mean the ability to live in a lower cost region, rather than near the major city centre where the office is located.  In fact, 48% of those who moved since the pandemic began, factored remote work into their decision.

Hybrid Work Choice

How can the Hybrid Work Model be an advantage for Employers?

 

Many of the advantages that may be seen as beneficial to employees are equally beneficial to employers. Implementing the ability to work remotely, offers employers:

Notably, when employers can recruit from a wider, more diverse group of people due to location flexibility, there is the potential to attract more and better candidates, including those who desire a hybrid work model due to their unique circumstances. And of course, it works both ways: Just as a broader talent pool benefits you as an employer, employees have opportunities that are not limited or defined by geography.

Remote work also appears to increase employee retention: “72% of employers say remote work has a high impact on employee retention—employees are sticking with their employer when they have remote work options.”

 

 

How are employers viewing the movement towards hybrid or even fully remote work?

According to a BDC study, 74% of SME owners say they will offer their employees the opportunity to continue to work remotely. This varies between organizations and person to person, but generally, employers appear to be understanding the dual benefits to offering a hybrid work model.  

 

 

Will offering a Hybrid Work arrangement help me in recruiting great employees?

Yes. Job seekers are asking for work location flexibility at an increasing rate and many are completely unwilling to take jobs where at least some remote work is not a possibility. Today, to be competitive, offering hybrid work is becoming more and more essential.

According to the BDC, 54% of employee say “access to remote work will be a determining factor” in both applying for or taking a job. When Arianna Huffington posted a poll to Linked In February 2022, asking ‘if you were to look for a new job, what’s most essential to you’? the results confirmed people have balance in mind. “Being able to work from home” got 34% of the vote, with 40% going to “Better life-work integration,” These two go hand-in-hand, one could argue.  

hybridwork April3

Will my employees leave if I don’t allow for a Hybrid Work Model?

For many, it’s a dealmaker/ dealbreaker. When surveyed, employees indicate they would consider leaving their job if they were forced to return full time to the office.

  • 43% are likely to look for a new job if their employer mandates a return to the office full time.
  • Almost 50% of Gen Z and Millennials would consider quitting if their employer didn’t offer remote work.

While it may seem extreme, the reality is that employees have many options now. With so many having been given the opportunity to experience working from home due to the pandemic, they are not willing to turn back.  

“Companies that refuse to support a remote workforce risk losing their best people and turning away tomorrow’s top talent.”- Stephane Kasriel, CEO of Upwork

With more and more progressive employers embracing the mindset that ‘it doesn’t matter where or how you work, just that the job gets done,’ why wouldn’t employees seek out these roles, given the majority of our workforce is telling us they want this?

Hybrid Work

How do Employers implement a formalized Hybrid Work model?

If you’re like many employers, prior to the pandemic, you may have had few or no employees working remotely, so never required a remote work policy.

The challenge? Determining how to integrate this work model in a more formalized way. If you’re like the majority of employers, you may lack a strategy.  As with any employee benefit, your approach needs to consider the values of your organization, the purpose of the benefit, in addition to the actual details of the new structure.  Consider:

  • Roles; which roles can be done fully remotely, versus those that require a worksite presence?
  • Put it in writing; details your expectations and employee responsibilities and revise employment contracts where applicable.
  • Structure; How many days in vs out? Is it a set policy? Is it different for different people/ different roles?
  • Personal circumstances; what works for one employee may be different from another and considering personal circumstances show employees you value them as individuals.
  • Support and Supplies; What will you provide employees to support their work from home? Tech equipment, supplies? Ensuring smooth tech is key to success.
  • Virtual check-in’s. How many are needed, and what are the requirements? Camera on or off?
  • Rethink your Key Performance Indicators; what was measured in the past may shift in a hybrid work model.
  • Management; ensure equal time for those in-office and those working remotely, and ensure communications and decisions do not favour one employee type over the other
  • In-person events and meetings; occasions to bring people together in person are valuable and a great opportunity to team build and improve morale.

There are many factors to consider, and like all employer decisions, taking the time to think through all the pieces is important. The impact of decisions surrounding WFH can be significant and deserve proper attention.

Is providing the option to work from home an ‘employee benefit’?

I would argue that this falls solidly under ‘total compensation.’ The flexibility to work from home is invaluable to so many people, and could be the difference in securing amazing team members. There is value in offering workplace flexibility, and it’s no surprise this is showing up as a key feature in many job postings.

hybridwork April5

Empower your employees: the smart choice to optimize productivity

At the end of the day, if you’re hiring good people that you trust, and the job is getting done, why not empower employees to make the choice as to the best place for them to be most productive? Trust goes a long way, in fact, according to the Harvard Business Review, employees in “high-trust companies” report

  • 74% less stress
  • 106% more energy
  • 50% higher productivity
  • 13% fewer sick days
  • 76% more engagement
  • 29% more satisfaction with their lives
  • 40% less burnout.

Adopting a hybrid work model shows you trust employees to get their work done effectively and on time, even when you can’t physically look over their shoulder. While it means making changes to how you manage and measure work, ultimately, it’s a work model that is here to stay and offers numerous benefits for everyone. However, like any employer decision, it’s best to formalize your expectations when it comes to working under a hybrid model.

Looking for assistance in developing your own employee benefits program and policies? We love to hear from you!

Sources:

 

Courtney, Emily.  The Benefits of Working From Home: Why the Pandemic isn’t the only Reason to Work Remotely. (Flex jobs).  https://www.flexjobs.com/blog/post/benefits-of-remote-work/

BDC.(June 15, 2021). Remote work is here to stay: BDC study. BDC. https://www.bdc.ca/en/about/mediaroom/news-releases/remote-work-here-stay-bdc-study

Birkinshaw, Julian, Cohen, Jordan, Stach, Pawel. (August 31 2020). Research: Knowledge Workers Are More Productive from Home. Harvard Business Review. https://hbr.org/2020/08/research-knowledge-workers-are-more-productive-from-home

Munro, Matt. (May 31, 2021). How Working from Home Increases Productivity. WBM Technologies.https://www.wbm.ca/blog/article/how-working-from-home-increases-productivity-infographic/

Kelly, Jack. (March 16th, 2022). Hybrid Will Be The New Work Style, But 72% Of Businesses Lack A Strategy, AT&T’s ‘Future Of Work’ Study Shows. Forbes.com. https://www.forbes.com/sites/jackkelly/2022/03/16/hybrid-will-be-the-new-work-style-but-72-of-businesses-lack-a-strategy-atts-future-of-work-study-shows/?sh=1c351e083989

Staff. (April 7, 2021). 90% of Canadian remote workers say working from home hasn’t hurt productivity: survey. Benefits Canada. https://www.benefitscanada.com/news/bencan/90-of-canadian-remote-workers-say-working-from-at-home-hasnt-hurt-productivity-survey/

Staff. (2022). Key Benefits of the Hybrid Work Model for Employers and Small Businesses. Rocketlawyer.https://www.rocketlawyer.com/business-and-contracts/employers-and-hr/company-policies/legal-guide/key-benefits-of-the-hybrid-work-model-for-employers-and-small-businesses

Staff. (October 4th, 2021). Majority of Canadians want to continue working remotely post-pandemic: survey. Benefits Canada. https://www.benefitscanada.com/news/bencan/majority-of-canadian-workers-want-to-continue-working-remotely-post-pandemic-survey/

Lindsay Byrka

Lindsay Byrka BA, BEd, CFP

Vice President, Immix Group: An Employee Benefits Company
A Suite 450 – 888 Dunsmuir St. Vancouver V6C 3K4
O 604-688-5262 E lindsay@immixgroup.ca
W www.immixgroup.ca

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