That risk adjusting and validated a piece of it. I would present several pieces that go into that calculation and im sure that is one, but im not sure its the main driver. I would be interested in seeing that level of detail. Sure. The higher the risk or the more medicare reimburses you, right . They were doing with the upcoding. Yeah, two components. So the higher risk score and again not an area of officexper but its the relative risk across the program. So medicare for us is not dependent on your utilization. Its Community Rated and then risk adjusted. On the commercial side its entirely utilization based. So if youre a higher utilizer, youre rate is higher. If youre lower risk, your rate is lower. On the medicare side, its a Community Rate approach and then adjusted for risk. So its an adjusted community rating. So the higher our total program is in risk, the more reimbursement we would receive, also dependent on geography and other factors. The risk adjustment that is changing whether we go up or down and what we do in terms of reconciliation from year to year, is we get final notification of what that reimbursement will be. And thats a portion of it. But a bigger portion is the risk adjustment on that Community Rate on whether your populations risk is higher or lower than others within that community. That is the change. So it doesnt necessarily mean your group got substantially sicker. Its the comparison amongst the entire medicare population that were rating as a community. Its not the most straight forward approach. It is not unique. It is what is different is that we actually do the reconciliation, where others will provide their best estimate and then that is the rate. Were saying if we come out early, we want to provide the right rate. We dont want it to be higher or lower than we need it to be. So we want to reconcile. If we were to do the rate in july or august, there would not be reconciliation from year to year. We would have the data we needed in order to develop a firm rate for you. To followup on the request, can you give us that data analysis, the past 35 years, because its curious to go from 13. 2 decrease to 11. 4 increase. Sure. And part of it is the swing. There is a reconciliation down and then reconciliation up. So its like the hip tax. When we took it off, it went down a point. When you put it on, it goes up a point. The delta is two points, even though its only a onepoint change. So a good portion of that is there is reduction going down and then a reduction going up, so it makes the swing really big. It is still big, its just not this big. Its only this big. But absolutely, we can provide that. Thank you. Thank you. The final thing ill note is the proposed 2020 rate for kpsa even with the increase is actually lower than what the 2018 rate was. So 2019 received a substantial benefit from this adjustment methodology. I know there is at least one vocal representative in our audience today that says people are not living on 2018 income, theyre living on 2020 income. And there is impact to them. President breslin any Public Comment on this item . Seeing none. Weve been doing this for an hour and a half. Would anybody like to item 14. Review approve Medicare Advantage preferred provider. Mike clark. So now were going to start our actual rate presentations with the United Health care Medicare Advantage ppo. The uhg ma ppo. As part of this discussion, if you look on page 2, the recommendations that we have to present to you today include two different scenarios, so one is what were calling a status quo scenario, that is just straight renewal. No Design Changes, no Program Changes, but we do feel that a package of one recommended Design Change and one recommended new program for the 2020 plan year is the suggested approach, the recommended approach, but we do have information on both scenarios in this document. You can see the rates on the middle of page 2 for 2019 plan year expressed on a per member, per month, or pmpm basis. So 2019, the rate currently is 371. 68 per medicare member. That is a. 7 decrease, thats due to the waiver of the aca hip tax. With aca hitback, 2020 rates are increasing 17 on a status quo basis, or 16. 6 with the combination of the plan Design Change and Program Change that were recommending today. I include for reference the page numbers for the actual rates and cards. And changes in total rates and member and employer contributions for each of these two scenarios. We will be suggesting and recommending for approval, the with proposed design and Program Changes approach. Well walk through that. So brief introduction which i mostly covered in the prior presentation in my opening statements, again, almost 16,000 medicare eligible retirees in this plan. Page 5, i talked about this as well, the fact that the majority of the increase is due to the return of the aca hip. This is 10 of the overall increase. The remaining 7 is underwriting claims and forecast, et cetera, so really the underlying insurance part of this renewal is a 7 increase. Which is in line with our National Health care costs trend expectations. And then just as reminder of page 6 when we set the total premiums you see today, we also include the Vision Service plan, vsp basic plan premiums as well as the Health Care Sustainability fund charge of 3 per retiree per month. And the Expert Opinion service is no longer offered starting in 2020. We formally included that in the cost. With the recent board decision to allow that contract to expire, youll no longer see those doctors in the rate cards. With that can i ask a question. Why are they applying the hit tax and kaiser did not . Its a function of what each particular organization, what they pass on their writs. Rates. United health care is choosing to pass it and kaiser does not pass it. Are there any rules that we dont allow either one . We have nothing to say about it . I can ask a kaiser and or United Health care representative to speak to their organizational positions. It is a tax that is placed on Health Insurers by the federal government, because these are full insured plans, its the Health Insurers responsibility to compensate the tax back to the federal government. Every plan differs in terms of their approach as to whether they choose to cascade it in theyre rates. Is there a Health Care Representative here . United Health Care Care . This is a huge addition to our increase. They all have to pay it. We understand that. Good afternoon. Hi, so from our perspective we see the hit tax, it is something we have to pay. So we see it as a passthrough only, so were just calculating the tax based on the equation given to us by the federal government and then passing that on to the client based on the premium. Its a 2. 01 . And each firm is taxed differently, depending on their tax status. We are forprofit company, so we get the full impact of the tax. But thats very much like some of the mandates that we have here in San Francisco and whether a person in a restaurant setting decides to pass on the full amount and increase their menu rates or whether theyre going to absorb that to some degree to maintain a client base coming to their restaurant. So im raising a question. Not about your tax status, but about the policy or the perspective of passing it totally through, versus assuming some portion of it. Absolutely. We do standardly pass the full thing through as a passthrough with all of our clients, regardless of size and status, et cetera. But i can absolutely take it back as a question. But its something that we have consistently passed through. I understand your current practice. Im asking for the rationale. The policy rationale as to why you would do that versus absorbing some portion of it on behalf of your members . I think thats the thrust of our question. Its 10 . And its a big hit. And so youve elected to do it. And im only asking why . Absolutely. And we can follow up with a direct answer on that. At this point in time, what weve been given as why we passed the tax through is because were being charged it. Its a cost of business that we dont typically have. Its been off one year, on the other. We do give a credit back each year when its not taxed, so were just doing a pass through. There is no calculation. It comes in after the fact of the renewal calculation. However, i can come back with additional responses. Thank you for the explanation. I have a question. Just one followup on the hit tax topic. If you recall from last month, kaiser does pass the hit tax in their nonmedicare premiums, theyre just not passed on the kpsa premiums. Ill explain each in further detail as to why we recommend these in subsequent pages. One plan Design Change is suggested to aid in lowering the premium rate increase for 2020, as well as to provide a coverage for the cost of the recommended new program below. So that is the increase the Specialist Office copay from 15 to 20 proposed. And then the new program to support members is 14 annual male benefit from moms meals nourish care. This is in addition to the program implemented in 2019 in this plan. To the copay change on page 9. Currently, office visit copayments for the uhg ma ppo are 5 for primary care provider. And 15 for a specialist physician. You can also see for kpsa 20 copayments apply for all office visits, primary or specialist. Were recommending the increase to 20 to partially offset the 17 rate increase. Its a 2. 50pmpm increment. But we also feel that the primary care physician copayment should remain at 5 to enhance the importance of primary care to members. And with the increased focus of enhancing access to quality and nutrition options to these medicare members, thats why we also recommend the new Meal Delivery benefit which we present on the next page, knowing that the funding for this benefit does come from this specialist copayment change. Just background on page 10. Around cms now allowing for medicare plans to allow enhanced benefits. You see the list of programs that were implemented for 2019 into the uhg ma ppo plan from transition support with Transportation Services and Meal Delivery post discharge, routine Transportation Services and Nutrition Counseling benefits. What were recommending with the 14 Meal Delivery which is the same organization that provides the post hospital discharge Delivery Service today. And more information on the moms and meals program, we list out on slide 11. So this is a onetime shipment of 14 meals, home delivered, freshly made, annually per member. These are regardless of medical requirements. So there is no particular diagnosis, no medical reason to then qualify for these. These are available to all members who participate in the uhg ma ppo program. They would call the service, moms meals nourish care to access the benefit. You can see an array of meal options to tailor to a particular individuals needs. Breakfast, lunch and dinner options are available and a wide array of culturally diverse meal options as well. The meals remain fresh in the refrigerator up to 14 days and can be frozen up to 90 days. So this comes in one shipment, 14 meals, members do have the ability to purchase meals on their own after this annual benefit has been exhausted at the cost of 6. 99 per meal with free shipping. The rate increase for this particular Meal Delivery benefit is 1. 05, pmpm. Quick question. Do you have any information i understand this is new in 2019 as a percentage of members that took advantage of that new program . So the post discharge Meal Delivery at this point, only two have taken advantage of the post discharge Meal Delivery. One did use the entire 84meal allotment. Another member used a 21meal allotment. I can follow up with the information on the Transportation Services and the enhanced access to nutritional counseling will follow up and have available for you after the meeting. President breslin how much extra did we pay for those meals, per member, per month . Ill have to follow up. I remember the total pmpm for all three, i just dont remember how they portioned out. You have 22 people using this, you know, these things need to be looked at. That just yeah, they certainly do. And one of the things that weve identified, a this is a function of a referral mechanism on a post discharge. And at discharge process in most hospitals is complex and there are many case managers involved. So clearly this is a very useful and needed, necessary benefit. The breakdown is occurring somewhere in the referral process. It could be i ran a number of these programs, the cms innovation programs and part of this is often having, in our case, the member know about it from a trusted source. So we have some responsibility here to make sure our members know when theyre offered these services that theyre sanctioned by us and theyre not something just falling from the sky. Because none of us really like strangers knocking on our door giving us anything, right . So it has to be from a trusted source. So there is work to be done. But the efficacy of post discharge in meals has been proven over and again, but we have to figure out have to get the uptake on the service. But two people out of 16,000 or whatever we have. Its ridiculous were paying for that. You know, of course its a good thing, but if nobody is going to use it, what good is it . And people dont trust that. Its like just for reference, so its available to anybody after a hospital discharge and that was three months the first three months of information, so granted a low number just with the recognition, thats a threemonth number. And only those discharged from hospitals would be able to access the benefit. Under this particular new program youre saying anybody can access it . Correct. So all members have access to this 14meal proposed benefit. Im sure my mother will turn over in her grave, she was a nutritionist. Its hard to question moms [laughter] four words in the program, nourish, meals, care. Theyre great words. Were not questioning the data or the value of post discharge nourishment and some monitoring of that, which this program could help, but i guess the question i have, are there data on providing 14 additional meals over the course of the rest of the year for whatever reason . I did go online and look at their website, and you know, its impressive. Everything is frozen. Im sure they have good vendors who make all this. And im sure its produced more locally and hopefully more sustainably, were not getting corn from somewhere outside our borders, but i dont know that this is really essential based on a datadriven analysis. That 14 more meals will make a difference for our members who are otherwise healthy and not been hospitalized or suffering illnesses that would complicate their ability to acquire good food from their family, friends or themselves. President breslin i just, when i first looked at this, 14 meals delivered at one time. So youre going to keep them in the refrigerator for a week or you can freeze them. They lose a lot of their nutritional value right there probably, but i just so this would cost 1. 05 per person per month for this nutrition program. And people are paying losing 5 on the copay for the specialist, so if you had the extra 5 for the copay, 10 of those would give you 14 well not quite 14, but they said you can purchase these meals for 6. 99. Well, thats not a bad deal, but to have this added i dont know. I just really question because i dont know anything about how the meals are. You know, i just dont know what kind of a deal this is. Costs 200,000 annually, probably for this plan. Correct. President breslin 200,000 plus annually. And we dont know how many people take it. Im all for people keeping healthy, as everybody knows, thats my big deal. And we have were also paying 3 for the Health Care Sustainability, for the Wellness Program basically. So this is kind of extra in that direction, but is it really effective . I just i really question it. I ask everybody else what they think about this. Im curious, the basis for the recommended add. The basis is that this is a social determinate of health is the adequate nutrition of our membership. All Health Care Systems are looking at how we can impact the health of our members outside of an institution. And so these programs that, you know, we started with the post discharge program, we already addressed those challenges. Then this program was a way to introduce our seniors that may not have access to affordable food, a way of getting that delivered to them appropriately and delving into addressing one of the major social determinates of health. I guess the question, is this something we should be doing, or the health plans should be doing it . People would hope that those in need of this would have the diagnoses and have access or the counseling about how to acquire this. The thing that bothers me about this, and the first proposal as well, is that were the people who are the most ill and see the most specialists are going to be paying more to see those specialists. And theyre already under financial strain. Now this alleviates a little bit of that. Provides 14 additional meals, assuming they havent been hospitalized, but i think its a small fraction of what they would be paying. I was a specialist. Im actually concerned more about the additional cost to our ill medicare members of seeing a specialist which is critical to their ongoing health, and 5 doesnt seem like much if youre only doing it once a year, but many of these people have several specialists that theyre seeing, sometimes monthly, or quarterly, or semiannually. And