Resource Guide 7 12 2016D

July, 2016
Resource Guide:
Health Insurance Choices for
Ohio Public Entities
Center for Public Policy and Health
Joshua Filla, MPA
Kimberly Laurene, PhD
Kathryn Bland, BA
Marissa Bland, BA
Heather Mikulski, MPP
Thomas Pascarella, DBA
Matthew Stefanak, MPH
John Hoornbeek, PhD, MPA
Sponsored by the
Ohio Department of
Administrative Services
© 2016 Kent State University. All rights reserved.

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Acknowledgements
We would like to acknowledge the valuable support and guidance provided by the Ohio Department of
Administrative Services (ODAS). In particular we would like to thank Stephanie Loucka, Joel Whetstone, and
Patrick Smith of ODAS for their leadership and insights as we went through the process of building our project
team and developing this document. We would also like to thank -- anonymously at this time -- the multiple
industry professionals who were kind enough to take time to share their knowledge with members of our
project team. In addition, we would like to thank Justin Brown and his colleagues with the State Employment
Relations Board (SERB), who provided valuable data and insights that enabled us to prepare this guide. We
would also like to thank Dr. Willie Oglesby and Dr. Rebecca Fischbein of Kent State University’s (KSU) College of
Public Health for their valuable insights and assistance. And finally, we would like to thank the health benefit
consortium officials who provided information about the work of their consortia, as well as the public entity
officials who shared information about their needs, practices, and experiences. While we benefited from insights
provided by all of these individuals, the work presented in the pages that follow may or may not reflect their
views.
Disclaimer
While Kent State University (KSU), its Center for Public Policy and Health (CPPH), and the Ohio Department of
Administrative Services (ODAS) have put in substantial efforts to ensure that this document contains helpful
information for public entities in Ohio, judgments regarding health insurance purchases are ultimately a
situation-specific matter and the responsibilities for which are best reserved to individual public entities. In
addition, officials should keep in mind that the insurance industry and its accompanying regulations are
constantly changing, and that the information presented in this document may become outdated based on
actions taken by government or private industry in the future. This Resource Guide seeks to provide local
officials with tools to help them make decisions regarding health benefit plans that they feel are best for their
employees, their organizations, and the citizens they serve. Neither KSU nor ODAS can accept responsibility for
consequences flowing from the individual choices made by Ohio public entities or others based on the
information presented in this Resource Guide. Accordingly, neither KSU, ODAS, nor their respective officers,
employees and/or agents, makes any warranty, express or implied, or assumes any legal liability or responsibility
for the accuracy, completeness, or any use of this Resource Guide. Further, neither KSU, ODAS, nor their
respective officers, employees and/or agents shall be liable for any direct, indirect, incidental, special, punitive
or consequential damages which may result in any way from use of the information provided in this Resource
Guide.
Note for Readers
The fields of healthcare and health insurance in Ohio are in the process of undergoing significant change, so
information provided here may become outdated. While we have made efforts to provide updated information
in this guide, readers are encouraged to supplement the information in this report with current or more recent
information whenever possible.

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Table of Contents
Introduction………………………………………………………………………………………………….............................. 4
The Basics of Health Benefit Plan Options ……………………………………………………………………………..... 5
Fully-Insured Health Benefit Plans…………………………………………………................................... 5
Self-Funded Health Benefit Plans......................................................................................... 6
Individually Purchased Health Benefit Plans........................................................................ 7
Health Benefit Consortia (Purchased by a Group of Employers)......................................... 9
Changes in the Insurance Market and how they affect Public Entities........................................ 11
The Affordable Care Act (ACA) and Related Regulatory Changes: An Overview............... 11
Community rating requirements for insurance providers ..................................... 12
ACA Requirements for Employers.......................................................................... 13
Health Benefit Plan Fees Under the ACA ............................................................... 14
Current Health Benefit Choices of Public Entities in Ohio............................................................ 17
Individual and Health Benefit Consortia Health Benefit Purchasing Arrangements.................... 18
Self-Funded and Fully-Insured Health Insurance.................................................. 20
Type of Health Benefit Purchasing Arrangement and Type of Insurance
Funding ................................................................................................................. 21
Making Health Benefit Choices: Steps and Considerations for Public Entities ............................ 23
Major Steps and Considerations in Purchasing Health Benefit Plans................................ 23
Special Considerations Related to Health Benefit Consortia............................................. 29
Conclusion..................................................................................................................................... 34
References .................................................................................................................................... 35
Appendices
Health Benefit Consortia in Ohio ....................................................................................... 40
Glossary of Key Terms and Concepts ................................................................................. 51
The Research and Information Development Approaches Used to Create This
Resource Guide .................................................................................................................. 71
Supplemental Readings ..................................................................................................... 75

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Decision Making Tool ......................................................................................................... 80
Figures and Tables
Table 1: Number of Health Benefit Plans Purchased by Ohio Public Entities for 2014 ... 10
Figure 1: Applicable Fees and Taxes for Fully-Insured and Self-Funded Plans................. 16
Figure 2: ACA Fee Timeline............................................................................................... 17
Table 2: Number of Medical Plans Offered by Ohio Public Entities by Total Sample,
Jurisdiction Type, and Eligible Employees for Health Benefit Consortia and Individual
Health Insurance .............................................................................................................. 19
Jurisdiction Type, and Eligible Employees for Self-Funded and Fully-Insured Plans ....... 20
Jurisdiction Type, and Eligible Employees for Type of Health Insurance Purchasing
Arrangement by Type of Funding .................................................................................... 22

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Introduction
This resource guide is designed to assist public entities in Ohio in making informed decisions about
health benefits they provide for their employees. It also seeks to help public entities determine
whether or not entering a health benefit consortium is appropriate for their organization. The public
entities benefiting from the information contained herein include general purpose local governments
such as counties, cities, villages and townships, as well as public colleges and universities, school
districts, and special purpose governments of various kinds.
The cost of health benefits and the health services covered under a health benefit plan can seriously
impact the health and wellness of public sector employees and their families. The costs of providing
health benefits can also have major financial impacts on the public entities themselves, and those costs
must be managed if the entity is going to sustainably operate to the benefit of those it serves. The
complex insurance marketplace and its corresponding state and federal regulations are elements of
decision-making processes that can become complicated and difficult to understand.
It is a good time for public officials to revisit how and where they purchase health benefits for their
employees. Healthcare costs have been rising for decades, and controlling increases in health care
costs has been an issue that public entities and their labor units have been working to address. In 2013,
for example, state and local level health care spending rose to $64.9 billion – a 19.6 billion increase
over the previous decade (Kaiser Family Foundation, 2015a). A national survey of local government
officials found that 71% of respondents felt that “employee health care costs” were one of their top
three operating concerns (International City/County Management Association [ICMA], 2011). The
federal government enacted the Affordable Care Act (ACA) in March of 2010 and new requirements
associated with this law have been taking effect since that time. It is important for public entity
officials to understand that these and other changes in the health insurance market are likely to affect
their health benefit plan options and choices over time.1
One important decision within the overall process of purchasing health insurance is for an entity to
choose whether to purchase a health benefit plan individually or collaboratively through a health
benefit consortium. Health benefit consortia are designed to pool the employees of participating
entities to create a larger risk pool and achieve economies of scale through the collaborative
administration of health benefits purchasing and claims management.
1
The Affordable Care Act actually refers to two separate pieces of legislation — the Patient Protection and
Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152).
Throughout this report, we use the “Affordable Care Act” (ACA) as shorthand for the cumulative changes
made in both of these pieces of legislation.

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This guide provides information on factors influencing the need for public entities to revisit where and
how they purchase health benefits, as well as information on basic health benefit plan options and
current health benefit purchasing practices of Ohio public entities. It also provides guidance on major
steps and considerations that should be taken into account when public entities revisit where and how
they purchase health benefit plans for their employees.
A listing of known health benefit consortia serving public entities in Ohio (Appendix A), a glossary of
relevant terms (Appendix B), a description of the research underlying this Guide (Appendix C), a
supplemental reading list (Appendix D), and a decision tool for public entities considering alternative
health benefit options (Appendix E) can be found in this document’s appendices.
The Basics of Health Benefit Plan Options
There are two primary forms of health insurance available for public entities to purchase: fully-insured
health benefit plans and self-funded health benefit plans. There are also two ways entities can
purchase health insurance products: individually or through a health benefit consortium. When
entities participate in a health benefit consortium, they purchase health benefit plans collaboratively
with other entities.
This section of this resource guide provides a brief overview of the different health insurance
purchasing options available to public entities in the State of Ohio. For the options identified in the
previous paragraph, each subsection provides a brief description of health benefit purchasing option,
along with a short list of potential advantages and disadvantages associated with that option. The
section closes with a brief overview of the health benefit purchasing plans chosen by a group of
(relatively large) public entities in the state.
Fully-Insured Health Benefit Plans
Fully-insured plans are typically purchased from a state licensed insurance company. In fully-insured
plans, premiums vary across employers based upon the employer size and employee population
characteristics (MacDonald, 2009). The insurance premiums are essentially charges from the insurance
carrier that are passed on as a fee for the coverage of benefits by that carrier (Fernandez, 2010).
Premiums may vary based upon age and use of tobacco (Giovannelli, 2014). Employers are typically
charged the same premium for each employee (MacDonald, 2009). In a fully-insured plan, the
employer pays a per-employee premium to an insurance company and the insurance company
assumes the risk of providing health coverage for insured events. The covered persons (i.e., employees

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and dependents) are responsible to pay any deductible amounts or co-payments required for covered
services under the policy (MacDonald, 2009).2
Potential advantages and disadvantages of fully-insured health benefit plans are described below.
Advantages:
 Administrative Services Provided: Typically, insurers offering fully-insured health plans
provide administrative services to assist their clients (Manning & Napier, 2013). For
example, applicable government fees tend to be incorporated into premium costs and
are then paid by the insurance company, so the public entity does not need to worry
about the administrative burdens of paying them.
 Do Not Have to Pay Excess Claim Costs: In any one year, the insurance companies
providing fully-insured plans accept the risk of paying the public entity’s claims, so the
entity does not need to be concerned about excess claims in any one year (Filice, n.d.).
Their up-front premiums are paid in part to get the insurer to pay for this risk.
Disadvantages:
 May be More Expensive than Self-Funded Plans: Fully-insured health benefit plans can
be more expensive than self-funded plans in Ohio, in part because these plans are
required to pay some fees that self-funded plans are not required to pay (National
Insurance Services, 2012).
 May Have Less Generous Health Benefits: There are cases where fully-insured plans
may have less generous health plan benefits than self-funded plans because self-funded
plans can be designed with the flexibility to meet the needs of the employer and their
employees (Manning & Napier, 2013).
Self-Funded Health Benefit Plans
Perhaps the main distinction between self-funded and fully-insured health plans is that self-funded
health plans are not purchased through an insurance carrier like fully-insured plans. Instead,
organizations with self-funded plans fund their own claims. In doing so, they may contract with a third
party administrator (TPA) that assumes duties associated with procuring health benefits and
2
Changes affecting fully-insured (and other) health benefit plans are occurring as a result of the ACA. These
changes (which may affect the future calculation of premiums for fully-insured products) are discussed later in
this report.

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administering them (Fernandez, 2010). Self-funded plans may not be purchased through a state
licensed insurance carrier, and these plans may not be subject to state regulations that apply to fully-
insured plans (Fernandez, 2010). This is true in Ohio.
Potential advantages and disadvantages of self-funded health benefit plans are described below.
Advantages:
 May be Less Expensive than Fully-Insured Plans: Self-funded health benefit plans may
be less expensive than fully-insured plans providing similar benefits because the
premium for fully-insured plans is based on the maximum expected claims cost and the
employer pays this fixed amount regardless of whether or not they incur the claims to
account for the premium. In addition self-funded plans are not required to pay certain
fees that fully-insured plans are required to pay (National Insurance Services, 2012).
 May have more Generous Health Benefits: Self-funded health insurance plans may be
more generous in their benefits than fully-insured plans. At least in part, this may occur
because they are not required to pay fees that fully-insured plans are required to pay
(Manning & Napier, 2013), and may therefore be able to fund more generous health
benefits for their employees.
Disadvantages:
 May Have to Pay Excess Claim Costs: In self-funded plans, the employer is liable for all
claims within any given year, so they may find that they need to pay out additional
funds at the end of the year that they have not anticipated (National Insurance Services,
2012). (However, this potential liability can be addressed by “stop loss” policies to
protect the employer.)
 Administrative Services Not Provided: In self-funded plans, the employer is responsible
for the administration of the plan and the payment of fees associated with it, so public
entities using self-funded health plans often need to maintain greater administrative
capacity than public entities purchasing fully-insured health benefit insurance policies
(Employer Health Advisors, 2011).
Individually Purchased Health Benefit Plans
The traditional method of purchasing health insurance products is for employers to compare, select,
and pay for their employees’ health insurance plans individually, rather than in collaboration with
other employers. Employers can select fully-insured products or self-fund their own coverage if they
have the financial capacity needed to cover the costs of their employees’ claims. Employers can also

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work with licensed insurance industry representatives to compare and acquire insurance for their
employees.
Potential advantages and disadvantages of individually purchased health benefit products are
described below:
Advantages:
 Complete Control of the Purchasing Process: An employer has complete control of the
purchasing process when they purchase health benefit plans individually. Employers
have the ability to craft and/or purchase a plan that meets their specific financial
situation and employee health needs (Field and Shapiro, 1993). This flexibility may not
always be available through health benefit consortia because – in those cases – the
needs of multiple employers must be taken into account.
 Flexibility for Future Changes: Employers are able to maintain flexibility to make future
changes to where and how health benefits are purchased. This flexibility may be
reduced when participating in a health benefit consortium (Wisconsin Association of
School Boards, 2014).
Disadvantages:
 Fewer Health Insurance Plan Options: Employers, especially if they are small, are
usually unable to offer individual employees the option to choose among several health
benefit plans due to administrative burdens associated with having contracts for
multiple health benefit plans (Wicks, 2002). However, health benefit consortia usually
permit individual employees to select from an array of plans with which the consortium
has negotiated contracts (Wicks, 2002).
 May be more Expensive than Health Benefit Consortia Plans: Individually purchased
health benefit plans may be more expensive than plans purchased through a health
benefit consortium. This may be particularly true for smaller employers who are not
able to take advantage of increased purchasing power and the sharing of administrative
costs that can occur with health benefit plans purchased through a consortium (Wicks,
2002).

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Health Benefit Consortia (Purchased by a Group of Employers)
A health benefit consortium is a group of employers that join together to purchase health benefits for
their employees. These consortia can purchase either fully-insured or self-funded health benefits for
their employees, although many existing health benefit plans offered by consortia in Ohio are self-
funded (see Table 1 below).
The specific forms of consortium organization and the plans offered vary depending on the needs of
the members. Some operate as a closed group of similar entities, such as a consortium operated by a
county Educational Service Center for local school districts. In fact, school districts have relied on
health benefit consortia for many years in Ohio. Other consortia operate more like private businesses,
advertise their products widely and seek to grow their membership. In some cases, a consortium may
contract with a TPA to manage its members’ claims.
Health benefit consortia also vary in the manner by which consortium members pay for the health
benefits they receive. In a “pooled” consortium, every member organization pays an equal amount to
support the consortium’s operations based on the overall risk of the entire population of member
organizations pooled together. In this case, the claims (and therefore costs) generated by each entity
may not be widely known among the members. By contrast, in an “allocated balance” health benefit
consortium, payment rates are based on individualized risk assessments for each member
organization. Higher risk member organizations may pay more compared to other member
organizations, and payments are based on the expenses of each participating organizational entity.
Advantages:
 Achieve Economies of Scale: Health benefit consortia help member entities achieve
economies of scale, which – in combination with enabling use of self-funded health
benefits – may reduce health benefit costs or enhance the generosity of benefits for
participating entities. This means that smaller public entities participating in consortia
may reap financial savings or enhanced health plan benefits similar to those achieved by
larger employers who can spread risk over larger numbers of employees (Barro, 2011).
 Service Benefits: Health benefit consortia may also provide service benefits to
participants who might not otherwise be able to administer their own self-funded
health benefits due to a lack of capacity and resources. In these cases, public employers
may be able to benefit from services provided by insurance professionals associated
with TPAs without having to employ these kinds of professionals themselves.

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Disadvantages:
 May Need to Pay Terminal and/or Legacy Costs: Members of health benefit consortia
may be required to pay “terminal” and/or “legacy” costs incurred by their consortium.
Terminal costs are funds owed by the consortia after it dissolves, and participating
entities may be responsible for paying these costs (NYSSBA, 2009). Legacy costs are
costs incurred by the consortia prior to an entity joining the group. In these cases,
public entities may be responsible to assist in paying these costs after joining the
consortium (NYSSBA, 2009).
 May Have to Share Control of Their Health Benefit Choices: Members of health benefit
consortia inevitably cede some degree of control over their health benefit choices to
other parties (Minnesota Life, 2009). In some cases, this may mean that they cannot
gain precisely the benefit plans they desire. In other cases, past organizational claims
histories or other characteristics of the organization’s employee base may prevent them
from getting optimal health benefit packages from the consortium in which they
participate.3
All four of the options described above are used by public entities in Ohio. Table 1 provides a snapshot
of the options used by public entities in Ohio who responded to a 2014 survey of Ohio public entities
on their health insurance choices that was administered by the State Employment Relations Board
(SERB, 2014B). The 2014 survey was sent to a sample of 1,327 public entities, and 1,231 of them were
completed by administrators from the jurisdictions involved -- a response rate of 92.8% (SERB, 2014B).
The 1,231 public entities provided data on 1,856 medical plans offered by their entity.
Table 1: Number of Health Benefit Plans Purchased by Ohio Public Entities for 2014
Purchasing
Arrangement
Form of Health Benefit Plans* Totals by
purchasing
arrangement
Full-Insurance Plans Self-Funded Plans
Individual Health
Plans
431 326 757
Jointly Purchased
Health Plans
(eg. “consortia”)
158 915 1,073
Totals by plan type 589 1,241 1,830
Note. Medical plans do not total 1,856 due to missing data associated with the Purchasing Arrangement and
Form of Health Benefit Plans questions in the 2014 SERB survey. Source: SERB 2014A.
3
For additional information on the advantages and disadvantages of health consortia please see the report,
“Adapting to the Changing Health Insurance Landscape: A Look at the Use and Effects of Health Benefit
Consortia by Public Entities in Ohio (KSU-CPPH, 2016).” It is available on the ODAS and KSU-CPPH websites.

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Additional information from this SERB survey is provided in Section IV, which provides readers with
information on current health benefit choices of public entities in Ohio. However, it is worth noting
here that the entities surveyed include relatively large numbers of K-12 school districts and larger
public entities, so the figures here are not necessarily representative of all public entities in the state of
Ohio. In Section IV, readers can access more detailed information on health benefit plan choices made
by different kinds of public entities in Ohio.
Changes in the Insurance Market and how They Affect Public Entities
There has been a long-term trend of increasing health care costs in both the United States (U.S.) and
Ohio. In the U.S., health care spending grew by 5.2% on average each year between 2000 and 2007,
and 4.1% on average per year between 2007 and 2010 (Council of Economic Advisors, 2014). In Ohio,
health care spending was $7,076 per capita with an annual growth rate of roughly 6% in 2009 (State
Health Facts, 2015). At that time, premiums were projected to continue to grow eight percent per year
(Multi State Plans, 2015).
These costs have potentially significant impacts on public entities in Ohio, which have already been
dealing with stresses to their budgets due to the recent recession and cuts in external funding sources.
At the same time, demands for quality services from constituents continue, and employee unions
continue to seek quality health benefit packages from public employers. Health care costs can
represent a significant amount of an entity’s annual expenditures, so exploring ways to provide quality
health care at the best price is an important process for public managers to undertake.
The ACA was passed into law by the federal government partially as a response to increasing health
care costs. The law made a number of important changes to existing health insurance regulations and
practices, and these changes have direct impacts on health benefit plans purchased by public entities
in Ohio.
The Affordable Care Act (ACA) and Related Regulatory Changes: An Overview
The federal government enacted the ACA in 2010. Public entities need to understand key elements of
the law, so they can both comply with its requirements and respond to its impacts on the overall
health insurance market. Three key areas of focus in this regard are new requirements relating to
community rating processes for establishing health benefit costs, new health-benefit plan
requirements for employers, and new fee structures which affect the relative costs of different health
benefit plan purchasing arrangements. Understanding these changes will allow officials from public
entities to make better decisions related to purchasing health benefits for their employees.

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Community rating requirements for insurance providers. A community rating is one way for
insurance companies to calculate the cost of insurance for a group. To calculate a community rating, an
insurer evaluates the risk factors of the entire market instead of any one individual employer, and
premiums are set based upon the spread of that risk across the group (Centers for Medicare and
Medicaid Services [CMS], 2013). As a result of recent regulations associated with the ACA, the Centers
for Medicare and Medicaid Services’ (CMS) now requires insurers to use new modified community
ratings that are based on four factors: age, smoking status, family size and geographic area for group
insurance health plans, within a community (CMS, 2015b). These four factors are then used to help
determine premiums for insurance in that community. In Ohio, a community is defined by counties
that are lumped together into 17 rating areas (CMS, 2015b). The community ratings rule is effective for
plan years that started on or after January 1st
, 2014.
Most large employers that are fully-insured or self-funded are exempt from being required to use the
modified community ratings (National Association of Health Underwriters, 2015.; United HealthCare
Services, Inc., 2013). For large employers, insurance providers may use “experience” rating, rather than
“community” rating, to establish health insurance costs. Experience ratings are based upon an
individual group (or employer’s) claims history, not the pooled factors of the community within which
they reside (CMS, 2015b).
Originally, the ACA increased the size threshold for “large group” health benefit markets to 101
employees starting in 2016 (it had been 51; CMS, 2014). However, the Protecting Affordable Coverage
for Employees (PACE) Act of 2015 has subsequently changed the threshold for large group to those
employers with 51 or more employees. The new (2015) law does appear to allow states to expand the
definition of small employer to those with up to 100 employees. This would mean that employers with
between 51 and 100 employees could be required to pay health benefit costs based on the new
modified community rating regulations starting in 2016 in states which choose to expand the definition
of “small” to include entities with up to 100 employees. This requirement could extend to public
entities, and it would mean that public entities within this size range, which have previously been
subject to experience rating, would then be required to have their health benefit costs established
through the modified community ratings processes described above.
Smaller public entities may be affected negatively by community ratings if any of the factors upon
which ratings are calculated (e.g. smoking status, age, family size, geographic regions) do not work in
the favor of the entity (CMS, 2013). Small entities with a young and healthy workforce may also see
premium increases due to the mandated restrictions leading to lower premiums for the less healthy
and older workers (Hamilton, 2013).
If the state decided to expand the definition of small employers, it would be likely to affect health
benefit costs for public entities. Employers should be aware of the potential for the threshold
separating large and small employer categories to change in the future. In Ohio, the definition of small

13
employer is having 2-50 employees (ORC 3924.01), and at the time of this writing, we are unaware of
any plans at the state level to change this definition.
ACA Requirements for Employers. The ACA contains a number of other requirements that may
affect Ohio public entities as employers. A summary of some of these requirements is provided below.
 Employer Shared Responsibility Provisions (Employer Mandate “Play-or-Pay”): The
Employer Shared Responsibility provision under the ACA states that employers
employing 50 or more full-time employees (or a combination of full-time and part-time
employees that is equivalent to 50 full-time employees) will fall under the Employer
Shared Responsibility provisions (Internal Revenue Service, 2015). This is stated under
the 4980H section of the Internal Revenue Code, which states that employees working
more than 30 hours a week or 130 a month are to be provided minimum level of
coverage by their employer or the employer will be subjected to fees (Internal Revenue
Service, 2015).
Public entities with 100 or more full-time equivalent employees (FTE) will need to insure
at least 70% of their full-time employees by 2015 and 95% by 2016. Employers with 50-
99 FTE will need to start insuring full-time employees by 2016 (Internal Revenue Service,
2015). The “play or pay” mandate does not apply to employers with 49 or fewer full
time equivalent (FTE) employees. The mandate applies to all employers – including
public entities -- with 50 or more FTEs. It also requires employers to (Internal Revenue
Service, 2015):
Provide Affordable Insurance: Coverage offered to employees must be considered
affordable (i.e., an employee’s share of the premium for employer-provided
coverage cannot cost the employee more than 9.5% of that employee’s annual
household income).
Provide Minimum Essential Value Insurance: Employer must provide minimum
value insurance (i.e., a plan provides minimum value if it covers at least 60 percent
of the total allowed cost of benefits that are expected to be incurred under the
plan).
 Minimum Essential Health Benefits: As noted above, employers of a certain size must
provide insurance for their employees. Health plans in the individual and small group
markets must provide a comprehensive package of items and services within at least the
following 10 categories (healthcare.gov, 2015):
o Ambulatory patient services
o Hospitalization

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o Maternity and newborn care
o Preventative and wellness services
o Emergency services
o Prescription drugs
o Rehabilitative services and devices
o Mental Health and substance use
o Laboratory services
o Pediatric Services
Health Benefit Plan Fees Under the ACA. The ACA also introduced a number of fees associated
with the choice of health benefit plans, and the changing costs associated with them is likely to affect
the desirability of different kinds of health benefit purchases for public entities. There are differences
in fees associated with choosing a plan that is self-funded or fully-insured. Self-funded plans
experience fewer fees from the ACA and do not have fees that are solely based on the size of the
entity.
There are currently six fees (not including the penalty fees for not complying with the requirements
discussed in the previous subsection) that have stemmed from the roll out of the ACA. As noted briefly
above, different fees apply to self-funded and fully-insured health benefit plans. In addition to
applicability by insurance type, whether or not a plan is “grandfathered” is also a factor contributing to
the applicability of certain fees. A health insurance plan is “grandfathered” if it was created or
purchased before or on March 23, 2010. Plans cannot be changed significantly or increase their costs
to the employees to maintain their grandfathered status. Grandfathered plans are also exempt from
providing preventative services at no cost to those enrolled in the plan or being subjected to rate
reviews for premium hikes (Marketplace Options, 2015). The new fees under the ACA are briefly
described below.
 Patient Centered Outcome Research Institute (PCORI) Fee: The PCORI fee is a fee on
insurers which will assist the PCORI, a non-profit corporation created by the ACA, in
giving patients a better understanding of prevention, treatment and care options
available and in advancing the quality and relevance of evidence-based medicine to
compile clinically effective research findings (PCORI, 2015). This is a temporary fee that
is in effect from 2012 to 2019 (PCORI, 2015). The PCORI fee is applicable to fully-insured
and self-funded plans (PCORI, 2015).
 Transitional Reinsurance Fee4
: This fee funds the Transitional Reinsurance Program,
which was established to stabilize premiums in the individual market both inside and
4
The Ohio Attorney General’s Office, ODAS, Warren County, and four state universities have filed a lawsuit in
U.S. District Court calling into question the constitutionality of the Transitional Reinsurance Fee (Ohio, 2015).
The lawsuit asserts that the Federal Government has overstepped its constitutional authority by levying broad

15
outside the State and Federal Marketplace and to cover administrative costs of
operating the reinsurance program (CMS, 2015a). The transitional reinsurance program
will collect fees from the contributing entities (health insurance issuers, self-insured
groups, and multiple group health plans) to fund the reinsurance payments to issuers of
non-grandfathered reinsurance-eligible individual plans (eligibility based on total annual
medical costs for covered benefits of an enrollee in an individual market plan (CMS,
2015c)), the administrative costs of the operation of the transitional program, and the
General Fund of the U.S. Treasury for the 2014-2016 benefit years (CMS, 2015a). The fee
is applicable beginning in 2014 to fully-insured and self-funded plans.
 Market Share Fee: The Market Share Fee is an annual fee on health insurers based on
each insurer’s market share of net annual health insurance premiums that are collected
(Congressional Research Service [CRS], 2013). This fee funds the premium tax subsidies
for low-income individuals and families that purchase insurance from the public
exchanges (Medical Mutual, 2015). The fee is permanent and went into effect in 2014.
The aggregate amount of fees to be collected across all users will be indexed to the
overall rate of annual premium growth (CRS, 2013).
 Risk Adjustment Fee: The risk adjustment fee funds government cost to administer the
Risk Adjustment Program. This program redistributes funds from plans with lower-risk
enrollees to plans with higher-risk enrollees to protect against adverse selection and risk
selection in the individual and small group markets, inside and outside the exchanges by
spreading financial risk across the markets (Kaiser Family Foundation, 2015b). This is a
permanent fee that is applicable to non-grandfathered fully-insured plans in metal tier
products (platinum, silver, gold and bronze) (Medical Mutual, 2015). In 2014, the fee is
$1.00 per member per year (Medical Mutual, 2015).
 Exchange User Fee: The exchange user fee exists to help fund and support the federal
exchanges (Medical Mutual, 2015). This fee is applicable to non-grandfathered fully-
insured plans. The effective date is 2014 with the health insurance carriers being
charged 3.5% of their premium for all business on a federal facilitated exchange
(Medical Mutual, 2015).
 Cadillac Tax: The Cadillac tax is a permanent annual tax taking effect in 2020 that is
placed on employers providing high-cost benefits through an employer-sponsored
group health plan. This fee will help to finance the expansion of health coverage from
the ACA’s health insurance mandate. This tax is applicable to fully-insured and self-
funded plans, regardless of grandfathered status. The fee amount is 40% of the cost of
plans that exceed predetermined threshold amounts. For planning purposes, the
tax assessments directly against State and Local governments and their instrumentalities. The term “fee” is used
in this Guide only because the term was used in documents consulted in the development of this Guide. Its use
here implies no comment regarding the lawsuit mentioned above. For more information on the State of Ohio’s
lawsuit please visit the Ohio Attorney General’s website. At the time of this writing the fee is still being
implemented by the Department of Health and Human Services.

16
threshold amounts are $10,200 for individual coverage and $27,500 for family coverage
and will be updated when final regulations are issued (Cadillac Tax Fact Sheet, 2015).
For example, an $11,000 individual plan would exceed the threshold by $800 ($11,000 -
$10,200 = $800). Therefore, an $11,000 individual plan would pay an excise tax of $320
($800 x 40% = $320) (Cadillac Tax Fact Sheet, 2015).
As stated above, the fees associated with the ACA are assigned via insurance type as well as based on
the size of the public entity involved. Public officials may want to take these factors into consideration
when choosing what type of health insurance to purchase. Figure 1 further illustrates how the fees are
distributed based upon insurance type and size of the entity.
Figure 1: Applicable Fees and Taxes for Fully-Insured and Self-Funded Plans
Insurance Type
Government Entity Size
Small
(100 or less Full-Time Employees)
Large
(101 or greater Full-Time Employees)
Self-Funded
Patient Centered Outcome
Research Institute Fee
Transitional Reinsurance Fee
Cadillac Tax
Patient Centered Outcome Research
Institute Fee
Cadillac Tax
Fully-Insured
Risk Adjustment Fee
Patient Centered Outcome
Research
Institute Fee
Market Share Fee
Exchange User Fee
Cadillac Tax
Patient Centered Outcome Research
Institute Fee
Market Share Fee
Exchange User Fee
Cadillac Tax
The insurance fee effective dates vary in their start dates from 2014 to 2020. Local officials should pay
attention to when certain fees and requirements apply to their public entity. Figure 2 illustrates the
time point at which various fees are scheduled to become effective.

17
Figure 2: ACA Fee Timeline
Current Health Benefit Choices of Public Entities in Ohio
The health benefit plans carried by Ohio public entities are very diverse. There is no one health benefit
plan to meet the needs of all entities. Entities vary by whether they individually purchase health
benefits or purchase them through a health benefit consortium. In addition, health benefit plans differ
based on whether they are fully-insured or self-funded plans. Furthermore, the desirability of the
health benefit plans varies by the costs and benefits related to the plan.
The purpose of this section is to describe current health insurance plans chosen by public entities in
Ohio, paying particular attention to practices that may differ across types of public entities (school
districts, cities, etc.).5
Data from the SERB 2014 annual survey of public entity officials’ benefit
purchasing practices are used to assess the prevalence of health benefit plans among different kinds of
public entities.6
By being aware of recent practices of different kinds of public entities, public officials
can gain perspective on the range of health benefit choices being made by other public entities in the
State of Ohio. The findings are presented in the narrative below and in Tables 2, 3, and 4.
5
It is important to recognize that the sample of public entities surveyed by the SERB is biased toward larger
public entities, by virtue of the Ohio Revised Code (ORC) language guiding its activities. The SERB survey also
samples school districts disproportionately. Readers should be aware of these biases as they review the
information provided.
6
We also spoke with a small sample of officials from jurisdictions serving fewer than 5,000 people to
supplement the analysis of the SERB data. Only 2/9 (22%) of the smaller jurisdictions offering health
insurance to their employees were involved in a health benefit consortium.
2012
• PCORI
2014
• Transitional
Reinsurance Fee
• Market Share Fee
• Risk Adjustment Fee
• Exchange User Fee
2020
• Cadillac Tax

18
Individual and Health Benefit Consortia Health Benefit Purchasing Arrangements
Table 2 displays the number of medical plans reported to SERB (2014A), which were purchased
through health benefit consortia and the number that were purchased individually.7
According to the
data presented, 58% of the health benefit plans appear to be purchased through a health benefit
consortium, while 42% of health benefit plans are individually purchased. When the type of health
benefit purchasing arrangement is assessed by the type of public entity, schools appear as the only
type of entity that selects health benefit consortia provided plans a majority (79%) of the time. When
taking the number of eligible employees for health benefits into consideration, health benefit plans
chosen by entities that have 51 to 100 eligible employees are much more likely to be purchased
through a health benefit consortium (74%) than individually purchased (26%). While public entities
that have less than 50 employees are slightly more likely to purchase health benefit plans individually
(56%), entities with more than 101 employees are slightly more like to purchase health benefit plans
through a consortium (55%).
Self-Funded and Fully-Insured Health Insurance. Ohio public entities’ choices of self-funded and
fully-insured health plans are reported in Table 3. The data in the table reveal that 68% of the health
benefit plans purchased by public entities responding to the SERB survey are self-funded while 32% are
fully-insured.8
When the type of health benefit funding is broken down by the type of entity, health
benefit plans chosen by schools, counties, and colleges/universities appear more likely to be self-
funded (82%, 75%, and 65%, respectively) than fully-insured (18%, 25%, and 35%, respectively).
However, townships, special districts (e.g., fire districts, regional transits, metro housing, and port
authorities), and cities appear more likely to purchase fully-insured health benefit plans (76%, 75%,
and 53%, respectively) than self-funded plans (24%, 25%, and 47%, respectively). When taking the
number of eligible employees for health insurance into consideration, entities that have 50 or fewer
employees are more likely to choose fully-insured (62%) than self-funded (38%) health benefit plans.
However, larger entities appear more likely to choose self-funded health benefit plans (51 to 100
eligible employees: 66% self-funded and 101 or more eligible employees: 73% self-funded).
7
Data reported from the SERB surveys may vary in sample size depending on the number of responses for
individual questions in the survey.
8
However, all of the smaller jurisdictions we interviewed (9/9) that offered insurance to their employees utilized
fully-insured plans.

19
Jurisdiction Type, and Eligible Employees for Health Benefit Consortia and Individual
Health Insurance
Purchased
through Health
Benefit Consortia
[# of medical
plans (%)]
Purchased by Individual
Public Entity
[# of medical plans (%)]
Total
(# of
medical
plans)
Total Sample 1075 (58%) 763 (42%) 1838
Jurisdiction Type*
Schools 850 (79%) 232 (21%) 1082
Cities 86 (26%) 243 (74%) 329
Counties 56 (39%) 86 (61%) 142
Townships 52 (39%) 80 (61%) 132
Special Districts 16 (20%) 65 (80%) 81
Colleges/Universities 15 (21%) 56 (79%) 71
Eligible Employees
0 to 50 120 (44%) 151 (56%) 271
51 to 100 249 (74%) 86 (26%) 335
101 and Higher 649 (55%) 526 (45%) 1175
Note. Totals and percentages are calculated across rows. Medical plans do not total 1,856 (the
total number of plans identified in responses received to the 2014 SERB survey) due to missing
data associated with the variables in the table.
* The State of Ohio is not included in jurisdiction type analyses, but it is included in the other
analyses.

20
Jurisdiction Type, and Eligible Employees for Self-Funded and Fully-Insured Plans
Self-funded
[# of medical
plans (%)]
Fully-Insured
(# of medical
plans (%)]
Total
(# of
medical
plans)
Total Sample 1242 (68%) 591 (32%) 1833
Jurisdiction Type*
Schools 883 (82%) 197 (18%) 1080
Cities 154 (47%) 172 (53%) 326
Counties 107 (75%) 36 (25%) 143
Townships 31 (24%) 100 (76%) 131
Special Districts 20 (25%) 61 (75%) 81
Colleges/Universities 46 (65%) 25 (35%) 71
Eligible Employees
0 to 50 103 (38%) 166 (62%) 269
51 to 100 221 (66%) 112 (34%) 333
101 and Higher 861 (73%) 313 (27%) 1174
Note. Totals and percentages are calculated across rows. Medical plans do not total 1,856 (the
total number of plans identified in responses received to the 2014 SERB survey) due to missing
data associated with the variables in the table.
* The State of Ohio is not included in jurisdiction type analyses, but it is included in the other
analyses.

21
Type of Health Benefit Purchasing Arrangement and Type of Insurance Funding. One can also
view Ohio public entities’ choices of health benefit purchasing arrangement by the type of benefit plan
(fully-insured vs. self-funded) to better understand their health benefit purchasing practices (see Table
4). Half (50%) of the health benefit plans in the sample of plans reported by SERB (2014) were
purchased from a health benefit consortium that is self-funded (50%). The next most common
arrangement reported to SERB (2014) is having individual-insurance that is fully-insured (24%),
followed by individual insurance that is self-funded 18%) and health benefit consortia that are fully-
insured (9%).
Across the various types of public entities, schools appear most likely to participate in a health benefit
consortium that is self-funded (72%). Townships appear to be most likely to purchase a fully-insured
health plan through a consortium (24%). Counties (44%) and colleges/universities (45%) appear most
likely to purchase health benefits individually and be self-funded, while cities (43%), townships (52%),
and special districts (62%) appear most likely to purchase insurance individually and be fully-insured.
One can also view health benefit purchasing practices in Table 4 based on public entity size. “Medium”
sized public entities appear most likely to participate in a health benefit consortium that is self-funded
(51 to 100 eligible employees: 60%). Larger public entities with 101 or more eligible employees
reported purchasing health benefit plans through consortia that are self-funded 49% of the time. By
contrast, public entities with 50 or fewer eligible employees appear most likely to purchase insurance
individually and be fully-insured (47%).

22
Jurisdiction Type, and Eligible Employees for Type of Health Insurance Purchasing
Arrangement by Type of Funding
Purchased through
Health Benefit Consortia
Purchased by
Individual Public Entity
Total [# of
medical plans]
Self-funded
[# of
medical
plans (%)]
Fully-Insured
[# of medical
plans (%)]
Self-funded
[# of medical
plans (%)]
Fully-Insured
[# of medical
plans (%)]
Total Sample 915 (50%) 158 (9%) 326 (18%) 431 (24%) 1830
Jurisdiction Type*
Schools 778 (72%) 71 (7%) 105 (10%) 125 (12%) 1079
Cities 55 (17%) 30 (9%) 99 (31%) 141 (43%) 325
Counties 43 (30%) 13 (9%) 63 (44%) 23 (16%) 142
Townships 20 (15%) 32 (24%) 11 (8%) 68 (52%) 131
Special Districts 5 (6%) 11 (14%) 15 (19%) 50 (62%) 81
Colleges/Univ’s 14 (20%) 1 (1%) 32 (45%) 24 (34%) 71
Eligible Employees
0 to 50 81 (30%) 39 (15%) 22 (8%) 127 (47%) 269
51 to 100 200 (60%) 49 (15%) 21 (6%) 63 (19%) 333
101 and Higher 577 (49%) 70 (6%) 283 (24%) 241 (21%) 1171
Note. Totals and percentages are calculated across rows, and percentages do not add to 100% in all
cases due to rounding. Medical plans do not total 1,856 (the total number of plans identified in
responses received to the 2014 SERB survey) due to missing data associated with the variables in the
table.
* The State of Ohio was not included in jurisdiction type analyses, but the State of Ohio was included in the
other analyses.

23
Making Health Benefit Choices: Steps and Considerations for Public Entities
This section provides an overview of a process public entity officials can consider for exploring
potential changes to their health benefit plans. It also focuses specifically on providing information
relevant to assisting public entities in determining whether or not joining a consortium is right for their
unique situations.
Major Steps and Considerations in Purchasing Health Benefit Plans
Like many significant decisions made by public officials, it is useful to think of decision-making about
health benefit choices as consisting of a number of key steps. And, for each step, there are
considerations to be addressed as it is undertaken. In this context, public entity officials may want to
consider viewing their health benefit plan choices as growing from a systematic process of information
collection, alternative identification and evaluation, and decision-making and management. The
information provided here is thus presented around six key steps, all of which are subject to multiple
considerations.
The key steps envisioned for making health benefit choices by public entities are:
1) Assessing and understanding the needs of the public entity and its stakeholders;
2) Identifying professionals and resources that can help officials understand their needs, and assist
them in identifying and evaluating their options;
3) Identifying health benefit plan options to consider;
4) Comparing promising options identified in step 3;
5) Making a decision based on the public entity’s needs and those of its stakeholders, and;
6) Assessing, evaluating, and adjusting choices over time.
The subsections that follow provide information relevant to proceeding through each of these steps, as
well as key considerations associated with each of them. In addition, in Appendix E, readers will find a
decision-making tool that may be of use to them in comparing health benefit plan options and deciding
on a health benefit plan that best meets their needs.
Step 1: Assess and Understand Needs
Each public entity will have its own set of needs and circumstances related to employee health
benefits. In this regard, public entity officials should consider:

24
 Their employees’ demographic make-up and past health claims. This matters when
considering plan types and how community or experience rating systems would be likely
to impact premium costs. In addition, understanding employee health needs will allow
officials to make decisions about what types of health programs and services should be
covered by the health benefit plan(s) they purchase.
 Their budgetary constraints. What type of health benefit costs can their entity’s budget
support?
 What stakeholder groups would be impacted by health benefit decisions and how would
they be impacted. Potential stakeholders include public employees and their families,
taxpayers, and labor unions. Is there an employee-management health committee that
should be consulted?
 What does the entity’s current health benefit plan look like? Is it a fully-insured plan or a
self-funded plan? Is it purchased individually or through a consortium? What are the
employees required to pay toward their coverage? What is the plan’s total cost? What
does the plan cover and provide for employees?
 How much latitude does the public entity’s official leadership have to make changes in
their health benefit plans? What relevant ordinances and/or requirements regarding
health benefit plan changes need to be considered? What collective bargaining
agreements are in place that might affect decisions regarding changes in health
benefits?
Health Benefit Committees Are Often Established
through Collective Bargaining Agreements
 The KSU-CPPH project team reviewed 285 collective bargaining
agreements (CBA’s) in the Ohio SERB’s online database.
 Of the 285 CBA’s reviewed, 136 (48%) included provisions establishing a
labor-management Health Committee.
Public Entities Must Often Work with Others
in Making Health Benefit Purchasing Decisions
 Of the 285 CBA’s reviewed, only 47 (16%) appeared to give public sector
managers complete control regarding decisions to make changes in employee
health benefit plans.

25
Officials should consider the items assessed in the bullets above as they assess their needs, and then
consider drafting specifications for what they want their health package to include. These
specifications could then be used to solicit proposals from insurance providers and/or third party
administrators, as appropriate.
Step 2: Identify Professionals and Resources that can Help Officials Understand Their Organization’s
Needs and Assist Them in Evaluating Options
Public entities in Ohio have varying capacities internal to their organizations to handle identifying,
evaluating, deciding upon, and administering health benefit plans for their employees. It is important
for officials to understand what expertise they have in-house and what external expertise may be
needed to help them make the proper decisions for their organization. In this regard, public entity
officials should consider:
 Whether or not they have their own Human Resources Department which has the
expertise needed to support their decision-making and administration of health
benefits.
 Whether or not they should consult with licensed industry professionals for assistance.
The Ohio Department of Insurance (ODI) licenses professionals in the insurance industry, and
individuals and organizations providing insurance related services must be licensed to do business in
Ohio (ORC, 3905; ORC, 3959). Licensed industry representatives are available to help officials with
identifying and comparing different insurance products. There are three main types of health insurance
licenses provided by ODI under its “accident and health” category (ODI, 2015).
 Insurance Agent - A person who sells, solicits, or negotiates insurance arrangements, as
per the Ohio Revised Code (ORC 3905.01).
 Business Entity - A corporation, association, partnership, limited liability company,
limited liability partnership, or other legal entity (that sells/solicits/negotiates insurance;
ORC 3905.01).
 Third Party Administrator - Is any person or organization that adjusts or settles claims in
connection with life, dental, vision, health or disability insurance plans, self-insurance
programs or other benefit plans for a sponsor of a plan if either the sponsor or the plan
is domiciled in this state or has its principal headquarters or principal administrative
offices in this state (ODI, 2015).

26
The ODI hosts a number of consumer tools online that may be useful to officials from public entities
who are working with insurance professionals:
 An agent locator that can be used to identify individual agents, insurance business
entities, and TPAs.9
 Public entities’ officials can obtain complaint histories of agents/brokers/ health
insurance corporations through the ODI website. The public entity official can enter the
name of the agent, for instance, through a search engine located under the
“administrative actions” link on the ODI homepage, to pull up records (“journals”) on
administrative actions taken by the agency. These records (“journals”) contain only
complaints that the ODI found reason to address with administrative action(s).10
 Services and resources are provided for public entity officials to use on the ODI website
for help with filing complaints. The website has a complaint form with a PDF document
that explains the complaint filing process on its website, along with an accompanying
easy to follow flow-chart.11
The appendices to this guide include a number of potentially helpful resources, including:
 A listing of health benefit consortia known or thought to be providing services to public
entities in Ohio and some basic information on their operations.12
(Appendix A)
 A glossary of terms used in the health insurance industry. (Appendix B)
 A list of supplemental readings relevant to health benefit purchasing for public entities.
(Appendix D)
 A decision-making tool that can be used by officials to assist them in evaluating specific
health benefit plan options and making decisions that meet their needs. (Appendix E)
9
https://gateway.insurance.ohio.gov/UI/ODI.Agent.Public.UI/AgentSearch.mvc/DisplaySearch
10
https://legacy.insurance.ohio.gov/journalsearch/journalsearch.aspx
11
https://www.insurance.ohio.gov/Consumer/OCS/Documents/HowtoComplain.pdf
12
The list of consortia in Appendix A to this document includes 34 (of 53) health benefit consortia that were
verified by the project team to be providing services to public entities in summer of 2015, and which provided
permission to be listed in this Guide. Information about these consortia and means by which they can be
contacted are also provided. Appendix A also lists the names of additional consortia reported to SERB (2014) to
be operating in Ohio at that time, but which did not respond to the project team’s inquiries during the
summer of 2015.

27
While none of these tools are likely to address all aspects of the information needed to make
appropriate health benefit plan choices, we hope and expect that the tools provided will be useful and
will make the job of making health benefit plan decisions easier than it otherwise might have been.
And finally, public entity officials should consider engaging with their peers to learn from their
experiences and apply those lessons to their own decision-making processes as they deem
appropriate.
Step 3: Identify Options
By using the resources identified above and investigating information on the past performance of
various insurance professionals, public entities should be able to generate a list of potential health
benefit options to consider. The organizations listed in the Appendix A to this Resource Guide would
be ones to consider for those public entities interested in exploring health benefit consortium options.
Once a handful of health benefit provider prospects are identified, the public entity should consider
soliciting proposals from three or more providers. Health benefit plan specifications should be drafted
first, so that all of the parties are quoting the same level of health benefits (see Step 1). These
specifications could overview the plan details and costs that an entity would like in a health plan –
much like is done for purchasing equipment or vehicles for public entities. However, the purchase of a
health benefit plan is not a lowest bid procedure, but a negotiated service contract.13
A public entity
can solicit proposals on its own, or through a licensed insurance broker or consultant.
There are numerous types of health benefit plans, numerous coverages, and resulting cost rates.
Officials should work to ensure that the proposals received meet or exceed the minimum coverages
outlined in their specifications. Once an official has received the written proposals and it has been
determined that it meets her/his minimum specifications, the next step is to compare the options.
Step 4: Compare Options
When comparing plan options, the following questions are important for a proper evaluation:
1. What are the price comparisons among the proposals? Cost is an important factor.
13
When looking at alternative insurance programs or consortia, public officials may be asked to provide a claims
history. They should obtain and/or request this information so they have it available for prospective health
benefit service providers. In many cases, existing health benefit providers should make available the annual
claims history for their covered organizations. This information can be utilized by prospective insurers to
measure risk factors and provide realistic ratings for entities. Some consortia may utilize these reports to
ascertain if a public entity would be a worthy member of their consortium.

28
a. Co-payments?
b. Deductibles?
c. Co-insurance percent?
d. Out-of-pocket maximums?
e. Yearly premium contributions?
2. What preferred provider network does a plan use? Will your employees be forced to switch
doctors because of the change in carrier?
3. What hospitals are on the proposed health benefit plan?
4. What does each proposal contain that goes beyond the minimum specifications?
5. Are there other non-quantifiable considerations that are important to an organization that
should be folded into the comparison?
The comparison of fully-insured products and self-funded products presents challenges. While both
kinds of products provide health benefits for the entity’s employees, the administration and provision
of services across these types of benefit plans are different. For example, a self-funded product may
be administered by a licensed TPA (third party administrator) that is hired to process and pay claims,
while a fully-insured plan might provide a different range of services. Differences in administrative
procedures and their potential costs should be considered. The decision making tool in Appendix E may
help officials with organizing and completing assessments of the alternative proposals they receive.
Step 5: Make Decision Based on the Organization’s Needs
Understanding the human health and fiscal needs of the organization, acquiring the necessary
expertise to support the decision making process, establishing minimum specifications, and identifying
and comparing alternatives will lead officials to a final decision on what type of health benefit plan
they need and what method to use when purchasing it. In general, this decision should be assessed
and evaluated with sufficient time and care, and in consultation with the organization’s key
stakeholders, as appropriate.
When making decisions regarding a health benefit plan to choose, it is necessary and appropriate to
recognize that adjustments in health benefit plans may need to be made over time.

29
Step 6: Assess, Evaluate, and Adjust over time
It is important for officials to continually assess, evaluate, and make adjustments in their health benefit
plan(s) as they obtain new information on its (their) impacts on their employees, stakeholders, and
financial situation. An insurance company or consortium may be able to offer a better deal for a
community that they were not able to provide previously. It may thus be a good idea for officials to
consider soliciting proposals for new health benefit plans over time, even if they are comfortable with
their current plan. There may in fact be better value in the market.
Also, things change within an organization. New employees come on board, other employees leave.
Budgets go up and down, and insurance markets continue to change. These changes need to be
accounted for as public entities assess, evaluate, and make adjustments in their health benefit plans
over time.
Special Considerations Related to Health Benefit Consortia
While the decision making process described above can be applied to both individually purchased and
jointly purchased insurance plans (eg. health benefit consortia), exploring health benefit consortia as a
potential option appears to make sense in the changing health insurance environment prevailing in
Ohio today. It also comes with some special considerations. The decision tool in the Appendix E
includes a framework for considering the questions described below:
1. How are costs allocated across the members of the consortium?
As noted above, in some cases, the costs of participating in a health benefit consortium
are allocated similarly across all members of the consortium equally. In other cases,
costs are allocated based on the claims experience(s) of particular members. While
both of these approaches may have their benefits for individual consortium members,
these benefits may not be the same for any particular entity.
Health Benefit Consortium Official Survey Results:
How are Member Contributions Established?
 41% (7/17) of the consortium officials surveyed reported that costs are
allocated equally across all of their consortium members.
 By contrast, 47% (8/17) reported that their consortium allocated costs
based on past claims experience within member organizations. As a result,
in these Health Benefit Consortia, members pay different costs.
* “Other” was selected by 2/17 consortium officials.

30
Public entities with particularly strong claims histories (e.g., relatively low levels of paid
out benefits) may fare better with an allocated balance consortium because their actual
costs may be lower than the costs of other consortium members. On the other hand,
public entities with relatively weak claims histories may benefit from more classically
organized “pooled” consortia for the opposite reason.
One thing to remember, however, is that claims histories may change over time, and
your organization’s recent claims history may not reflect future claims, so your entity’s
specific financial interests may change over time.
2. Can organizations bring their existing plan to the consortium?
a. Can an organization bring their existing plan to the consortium, thereby insuring its
employees that there will be no change in coverage levels?
b. Are organizations required to select an existing plan offered by the consortium?
1. How many plans are available?
2. Are any plans identical or very similar to an organization’s existing plan?
Public entities may want to insure that their savings are the result of administrative
savings and/or fee savings and not the purchase of less coverage for their employees
and their families.
Health Benefit Consortium Officials Survey Results:
Are Health Benefit Consortia open to new plans?
 About half (8/17) of the consortium officials indicated that their consortium
was open to establishing new plans requested by members.
 The other half (8/17) of surveyed consortia only offered a standard plan or
set of plans to members.
* “Other” was selected by 1/17 consortium officials.

31
3. What are the rules for joining a consortium?
a. Are there fees to join the consortium?
b. Are there continual fees that would need to be paid regularly over time?
c. What is the length of the agreement?
The answer to these and other questions should be included in the consortium’s bylaws
and/or governing documents.
4. What are the rules for leaving health benefit consortia?
Once again, it is appropriate to ask a number of questions.
a. Must written notice be provided to leave?
b. How long in advance must notice be provided? Are there specific time periods for
notifying the consortium of a member’s desire to leave?
c. Does the consortium provide a claims history regularly so that an organization can
utilize this history to get quotes from other insurance organizations in the future?
How Many Plans do Consortia typically have available to members?
 The majority of responding consortium officials surveyed (10/15) indicated
that their consortium offered between one and three medical plans with
the most common number of medical plans offered being one (5/15).
 The other consortia officials (5/15) reported the number of plans offered to
members was from 6 to 7 medical plans all the way to an unlimited number
of plans.
Rules for Joining a Consortium
 63% of the consortia interviewed/surveyed had restrictions based on the
type of public entities allowed into the consortium (n=35).
 31% of consortia interviewed/surveyed had restrictions based on
geographic location of member entities (n=35).
 Of those consortia that responded, 58% had restrictions that were based
on “acceptable” claims histories for prospective members (n=17).
 Minimum size (18%) and maximum entity size (12%) were also restrictions
noted by some of those surveyed (n=17).

32
d. How is the “run out” of claims addressed? If there are claims that have been
incurred by a consortium member’s employees but not yet submitted or paid, will
they be paid after it has exited the consortium since they were incurred while the
entity was a member?
e. Upon departure, would an entity receive its portion of any cash reserves that it has
paid and have accumulated during its membership period?
5. How stable is the consortium?
a. How long has the consortium been in existence?
b. What are the levels of its cash reserves?
c. What are the recent trends with its cash reserves? Have they been increasing or
decreasing?
d. What is the number of members?
e. What is the number of lives covered?
f. What is the recent history of entering and exiting members?
Rules for Leaving a Consortium
 71% (11/17) of the officials surveyed indicated that their consortium did not
allow their members leave at any time without penalty.
 Among responding consortia, the average required duration for
membership is about two years (n=10).
Stability of Consortia
 Jointly purchasing health insurance is not a new idea. A majority of the
health benefit consortia responding to our survey had existed for more
than 20 years, and many of these long-lasting consortia served school
districts (n=17).
 About 64% of the consortium officials surveyed who were affiliated with
organizations that have existed for at least 5 years indicated that their
consortium showed growth over the past five years, while 14% showed
decreasing membership and 21% stayed the same (n=14).

33
6. Is the consortium located in close physical proximity to the public entity?
Some organizations are simply more comfortable knowing that the consortium is located in
their area. With modern communication, other entities may be indifferent to this issue.
7. What are the present cost rates? How have they been changing in recent years?
For public entities, it is often helpful to have stable and relatively predictable health benefit
costs, as this may improve the entity’s ability to plan and budget for the future.
8. Do labor unions have a role in this decision?
a. Organizations need to know if their union contracts require union approval of
changes in health benefit plans, and/or changes from individual purchased plans to
consortium based plans?
b. Do collective bargaining agreements require a renegotiation for changes in health
benefit plans and/or movement to consortium based arrangements?
Labor Unions Often Play a Role
in Making Health Benefit Purchasing Decisions
 Our project team reviewed 285 Collective Bargaining Agreements (CBAs) in
SERB’s online database and found that:
o Unions had influence in the health benefit decision-making
process in about 58% (166/285) of the CBAs reviewed.
 Unions had effective approval/veto power specified in
36% (102/285) of the agreements.
o Managers had significant latitude in the health benefit decision
making process in about 42% of the CBAs reviewed.
 In 26% (119/285) of the CBA’s reviewed, public managers
had constraints on the health benefit decisions they
could make clearly articulated in the CBA.
 Managers had complete control of the process in only
16% (47/285) of the CBAs reviewed.

34
Using the decision-making processes identified above and devoting attention to the considerations
described in this section, public entity officials should be able to create a sensible framework for
making health benefit purchasing decisions which benefit their employees and their families, their
organization, and the constituent they serve.
Conclusion
Budgetary challenges facing public entities in Ohio and changes in the health insurance market and its
regulatory requirements are forcing public officials to revisit how and where they are purchasing
health benefits for their employees and their families. There are many different forms of health benefit
packages, including self-funded plans and fully-insured plans. Health benefits can also be purchased
individually by an organization or through a health benefit consortium. Many public entities in Ohio,
especially school districts, are purchasing their health benefits through consortia.
While consortia have been utilized by public entities in this state for many years, each entity’s situation
is different and, as a result, public officials need to conduct their own decision-making processes that
take into consideration their organization’s own unique situation and needs. This Resource Guide has
suggested many factors that can be taken into consideration, and it poses a number of questions that
public entity officials may ask of various health benefit providers. The Guide also offers a decision
making tool in Appendix E that may be helpful for officials to use in comparing different plans, and in
exploring consortia as an option for purchasing health benefits. There may very well be other tools and
resources that exist for use by these entities, and officials should find what works best for their own
situations.
The changing health benefit landscape in this country presents a challenge for public managers.
Engaging in a stepwise process to identify, compare, and select what type of health benefit product
works best for an individual organization will help public officials to make decisions that have a positive
impact on their employees, their employees’ families, their constituents and stakeholders, and the
public entity as a whole.

35
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Shared-Responsibility-Provisions-Under-the-Affordable-Care-Act
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explorer/?display=U.S.%2520%2524%2520Billions&service=All%2520Types%2520of%2520Servi
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brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/
Kent State University – Center for Public Policy and Health. (2016). Adapting to the Changing Health
Insurance Landscape: A Look at the Use and Effects of Health Benefit Consortia by Public
Entities in Ohio, Kent State University, Sponsored by the Ohio Department of Administrative
Services.
MacDonald, J. (2009). Health Plan Differences: Fully-Insured vs. Self-funded. Retrieved June 16,
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Manning & Napier (2013). Health Plan Funding Options: An Employer’s Decision Guide.
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funding-options.pdf
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https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/
Mayer, K. (2013). PACA spurs rising interest in self-funded plans. Retrieved October 10, 2015 from
http://www.benefitspro.com/2013/04/15/ppaca-spurs-rising-interest-in-self-funded-plans
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https://www.medmutual.com/Healthcare-Reform/Reform-for-Employers/Federally-Mandated-
Fees-Impacting-Employers.aspx

38
Minnesota Life (2009). Buying Power: How Consortiums are Changing the Benefits Landscape.
Retrieved September 27, 2015 from
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National Association of Health Underwriters (2015). Consumer Guide to Group Health Insurance.
Retrieved October 10, 2015 from https://www.nahu.org/consumer/GroupInsurance.cfm
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http://www.irs.gov/uac/Newsroom/Patient-Centered-Outcomes-Research-Institute-Fee
New York State School Boards Association (NYSSBA). Can Health Insurance Consortiums Rein in School
District Health care Costs? (2009,September 1).Retrieved January 20, 2015, from:
http://www.nyssba.org/clientuploads/nyssba_pdf/ConsortiumReportFinal.pdf
Ohio (2015). The State of Ohio v United States of America Action Case No. 2:215CV0321. Retrieved
August 27, 2015 from http://www.ohioattorneygeneral.gov/Files/Briefing-Room/News-
Releases/Policy-and-Legislation/2015-01-26-State-of-Ohio-et-al-v-US-of-America-Tim.aspx
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Ohio Revised Code (ORC). (2015). Lawriter – ORC. Retrieved August 13, 2015, from:
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39
State Employment Relations Board (SERB) of Ohio. (2015). SERB 2015 Health Insurance Survey:
Consortium Survey Questions [Data file & code book]. (personal communication, April 2, 2015).
State Health Facts. (2015). Retrieved May 19, 2015, from http://kff.org/statedata/
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mmunity/ACR_FAQ.pdf
Wicks, E. K. (2002). Health insurance purchasing cooperatives. Commonwealth Fund. Retrieved from
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Cooperative Right for Your District? Retrieved September 27, 2015 from
http://wasb.org/websites/wisconsin_school_news/File/2014June-July/Insurance_June-
July_2014.pdf

40
Consortia Name Contact Address Phone Email Website
Types of
Public Entity
Served
Geographic
Restriction
Ashtabula County
Schools Council of
Governments
Jerome
Brockway
PhD
1565 State
Route 167.
Jefferson,
Ohio. 44047
440-
576-
6015
jerome.brockway@atech.edu
School
Districts Only
Ashtabula
County ONLY
Brown County
Schools Insurance
Consortium
James
Frazier
9231 B
Hamer Road,
Georgetown,
OH 45121
937-
378-
6118
james.frazier@Brown.k-12.oh.us
Educational
entities
Educational
entities
residing in
rural
Southern
Ohio
Central Ohio Health
Care Consortium
Matt
Peoples
36 High
Street Canal
Winchester,
Ohio
614-
834-
5111
mpeoples@canalwinchesterohio.
gov
Organizations
that are
defined as a
public entity
by the ORC
(municipalities
and special
districts, etc.)
No
Restrictions
Clermont County
Insurance
Consortium
Jeff Weir
2400
Clermont
Center Drive,
Suite 100,
Batavia, OH
45103
513-
735-
8300
weir_j@ccesc.org
No
Restrictions
Would
consider
including
school
districts in
other
counties
Appendix A: Health Benefit Consortia in Ohio
Health Benefit Consortia Confirmed to be in Operation, Summer 2015

41
Consortium Name Contact Address Phone Email Website
Types of
Public
Entities
Served
Geographic
Restriction
County Employee
Benefits
Consortium of Ohio
(CEBCO)
Doug Foust
209 East
State St.
Columbus
Ohio 43215
614-
220-
7984
dfoust@ccao.org
www.cebco.org
Counties only
No
Restrictions
Employers Health
Purchasing
Corporation
Mike Stull
(Chief
Marketing
Officer)
5775
Perimeter
Dr. Dublin,
OH 43017
614-
763-
0007
mstull@employershealthco.com
http://www.employershealthc
o.com/
All Entities
No
Restrictions
Franklin County
Cooperative Health
Benefits Program
Margaret
Snow
373 S. High
St., 25th
Floor,
Columbus,
OH 43215
614-
525-
5539
mksnow@franklincountyohio.gov http://bewell.franklincountyoh
io.gov/
Local
government
and other
special
districts
No
Restrictions
Great Lakes
Regional Council of
Government
Amy
Hendricks
21620
Mastick
Road,
Fairview
Park, OH
44126
440-
331-
5500 X
1119
ahendricks@fairview.k12.oh.us www.fairviewparkschools.org All entities
No
Restrictions
Hardin County
Schools Consortium
Rick Combs
P.O. Box 98
Dola 45835
419-
759-
2100
hccombs@wcoil.com
Public Schools
only
No
Restrictions

42
Types of
Public
Entities
Served
Geographic
Restriction
Health Action
Council
Patty Star
6133
Rockside Rd
Suite 210
Cleveland,
Ohio 44131
216-
236-
0362
pstarr@haco.org www.healthactioncouncil.org All entities
No
Restrictions
Health Transit Pool
of Ohio
Barbara
Rhoades
1 Park
Center Drive
#330
Wadsworth,
Ohio 44281
330-
334-
6877
BarbaraR@healthtp.org www.healthtp.org
Must be an
Ohio public
transit formed
under Ohio
statute, RTA,
CTB, or an
individualized
department of
a county
No
Restrictions
Huron-Erie School
Employee
Association
Sharon
Mastrioni
316 W
Mason Road
Milan, OH
44846
419-
499-
4663
smastroi@ehove.net
Public School
Districts
No
Restrictions
Inter-University
Council Purchasing
Group
Cindy
McQuade
10 West
Broad Street,
Suite 450
Columbus,
Ohio 43215
614-
464-
1266
Mcquade.2@osu.edu
Serve public
four-year
universities
and 2-year
colleges
No
Restrictions

43
Types of
Public
Entities
Served
Geographic
Restriction
Jefferson Health
Plan/Umbrella Plan
Separate Health
Benefit Pools under
Jefferson Health Plan:
Center for Local
Government (CLG)
Health Benefit pool
Ohio Public Employer
Cooperative
Sandusky-Ottawa
County Pool
(San-Ott)
Ohio Benefits
Cooperative
Ohio Valley Pool
South Central Ohio
Insurance Consortium
(SCOIC)
Erie Shore Pool
David
Manning
1755 Indian
wood Circle,
Suite 100,
Maumee, OH
43537
419-
794-
7330
dmanning@burnsconsulting.com www.jeffersonhealthplan.org
All entities
No
Restrictions

44
Consortium
Name
Contact Address Phone Email Website
Types of
Public
Entities
Served
Geographic
Restriction
Lake County
Board of
Commissioners
Joel Dimare
(440)-
350-
2366
Joel.Dimare@lakecountyohio.gov
Only County
departments,
county
boards,
townships and
municipalities
in Lake County
Lake County
( would
consider
political
subdivisions
from other
Counties)
Lake County School
Health Care
Benefits Program
Michael
Vaccariello
440-
428-
9328
michael.vaccariello@madisonscho
ols.net
School
districts and
educational
entities
No
Restrictions
Lawrence County
Schools Council of
Government
James
Payne
111 S 4th
Street 3rd
Floor Court
House
Ironton, OH
45638
419-
436-
4085
james.payne@lc.k12.oh.us
Serve a group
of educational
entities –
Local School
Districts, ESC
No
Restrictions
Logan County
School Employee
Consortium
Robert
Kuehnle
4740 County
Road 26
Bellfontaine,
OH 43311
937-
593-
9211
kuehnler@benjaminlogan.org
School
Districts
No
Restrictions

45
Types of
Public
Entities
Served
Geographic
Restriction
Mahoning County
Employees
Insurance
Consortium
Dr. Ronald
J. Iarussi
100
Debarpolo
Place
Youngstown,
OH 44512
330-
965-
7828
r.iarussi@mahoningesc.org http://www.mahoningesc.org/
School
Districts Only
No
Restrictions
Mercer Auglaize
Benefit Trust
Steve
Dandurand
PO Box 906
Fostoria, OH
44830
419-
436-
4085
sdandurand@corporateonebenefit
s.com
Local School
Districts Only
Mercer and
Auglaize
Counties
Metropolitan
Education Council
Suzie Strait
614-
336-
8030
sstrait@andrewins.com
All entities but
serves schools
districts
No
Restrictions,
but
primarily in
central Ohio
Midwest Employee
Benefit Consortium
Erica
Preston
Alt.
Contact:
John
Bergman
2095
Blackhoof
Street,
Wapakoneta,
OH
419-
739-
6710
epreston@auglaizecounty.org
County and
Health
Districts
Mercer ,
Auglaize and
Hancock
Counties
North Central Ohio
Trust Dr. Larry
Cook
928 West
Market
Street, Suite
A, Tiffin,
Ohio 44883
419-
447-
2927
lcook@ncoesc.org www.ncoesc.org
School
Districts Only
Seneca
County Only

46
Types of
Public
Entities
Served
Geographic
Restriction
Ohio Public Entity
Consortium
Erin Patton,
CFO
P.O. Box
1135 Dublin
Ohio 43017
614-
873-
6000
epatton@ohiopublicentity.com
www.ohiopublicentityconsorti
um.org
All Entities
No
Restrictions
Ohio Public
Healthcare Risk
Pool
Steve Hopp
Two Summit
Park Drive,
Suite 235,
Independenc
e OH, 44131
234-
380-
4466
steve_hopp@ajg.com
To participate,
the public
entity must be
a Housing
Authority in
Ohio
No
Restrictions
Ohio School
Benefits
Cooperative
Christine
Wagner
205 N 7
th
St.
Zanesville
OH 43701
740-
452-
4518
Christine.wagner@mvesc.org www.mvesc.org
Only School
Districts
No
Restrictions
Southwest Ohio
Organization of
School Health
Valerie
Bogdon-
Powers
4990 East
Galbraith
Road
Cincinnati,
Ohio 45236
513-
745-
0707
valerieb@horanassoc.com http://myswoosh.org/
All public
entities
No
Restrictions
Southwestern Ohio
Educational
Purchasing Council
Doug
Merkle
303
Corporate
Center Dr.
Suite 208,
Vandalia, OH
45377
937-
890-
3725
doug.merkle@epcschools.org
epcschools.org
Public School
Districts and
County Boards
of
Developmenta
l Disabilities
No
Restrictions

47
Types of
Public
Entities
Served
Geographic
Restriction
Stark County
Schools Council
Joe
Chaddock
2100 38th
NW, Canton,
OH 44709
330-
492-
8136
joe.chaddock@email.sparcc.org
http://www.starkcouncilofgov.
org/
index.php?page=insurance
All public
entities
No
Restrictions
Suburban Health
Consortia
Glen Szana
Group
Health Care
Consulting
1616 E
Wooster
Suite 20
Bowling
Green, OH
43402
419-
354-
7500
gszana@ghconsulting.com
Currently only
Local School
Districts
No
Restrictions
Summit County
Health Connection
Wendy
Weaver
175 S Main
St Akron, OH
44308
330-
643-
2783
wweaver@summitoh.net www.co.summitoh.net
Political
subdivisions
only: Cities,
Villages,
Townships,
County
Only Summit
County
Teamsters Local
377 Health and
Welfare Fund
Rita Banks
1223
Teamster
Drive
Downstairs
Office
Youngstown
Ohio
330-
744-
3148
rbanks@neo.rr.com
Members of
Teamsters
union and
belong to local
377
Employees
have to be
members of
Teamsters
Local 377
(Youngstown
area)

48
Note: The listing above includes known health benefit consortia providing services to public entities in Ohio. The consortia listed were confirmed as being in operation
in the Summer of 2015. Nineteen additional health benefit consortia, which were reported by third parties as providing services to public entities in Ohio, are listed
below. The project team tried, but was not able, to reach these 19 additional consortia during the Summer of 2015 to verify their continuing services and to collect the
kind of information that is presented above. In addition, an Appendix to the document, “Adapting to the Changing Health Insurance Landscape: A Look at the Use and
Effects of Health Benefit Consortia by Public Entities in Ohio”, which was released by the KSU-CPPH and the Ohio Department of Administrative Services in the Summer
of 2016, includes a full listing of consortium names from the tables above and below.
Types of
Public
Entities
Served
Geographic
Restriction
Trumbull County
Schools Insurance
Consortium
Lori
Simione
6000
Youngstown
Warren Rd.
Niles Ohio
44446
330-
505-
2800
Lori.Simione@neomin.org All entities
No
Restrictions
Wayne County
Employee Benefit
Plan
Patrick
Herron
428 West
Liberty
Street
Wooster,
Ohio 44691
330-
287-
5400
pcherron@wayneoho.org http://www.wayneohio.org
Serves entities
defined as
political
subdivisions
by the ORC
Only Wayne
County

49
Other Health Benefit Consortia Reported to be Operating in Ohio
This list of consortia was obtained from the 2014 and 2015 State Employment Relations Board (SERB) Insurance Surveys, and is included to provide a
more extensive list of Ohio health benefit consortia. The project team was unable to confirm contact information with officials with the consortia
included on this list, and therefore, do not present that information here.
Consortia Name Address Website
Allen County Schools Health Plan 9105 Harding Hwy. Harrod, OH 45850
https://pcms.plansource.com/entities/31046/pub_node
s/1019
Buckeye Ohio Risk Management Association 255 W. Riverview Napoleon, Ohio 43546
County of Lorain Health Plan
6155 Park Sqre. Dr., Ste. 7
Lorain, OH 44053
http://www.loraincounty.us/commissioners-
departments/personnel
Cuyahoga County Healthcare Regionalization
Program
2079 E. 9th St., Cleveland OH 44115
http://regionalcollaboration.cuyahogacounty.us/en-
US/Healthcare_Regionalization.aspx
Greater Cincinnati Insurance Consortium 4977 Delhi Ave, Cincinnati, OH 45238
http://www.gc-insurance.com/contact.aspx
Hancock County School Consortium 7746 County Road 140 Findlay, Ohio 45840
Lake Erie Regional Council of Governments 1885 Lake Avenue Elyria, Ohio 44035
Ohio School Employee Insurance Consortium
(OSEIC)
6075 Manchester Rd. Akron, Oh 44319
Optimal Health Initiatives (OHI)
P.O.Box 194 345 N. Chillicothe Street Plain City, OH
43064
http://www.ohi-online.org/
Paulding County School Consortium 405 North Water Street Paulding, Ohio 45879-1251
Pickaway County Public Employees Benefit
Consortium
9579 Tarlton Road
Circleville, Ohio 43113
Portage Area School Consortium Portage County, Ohio

50
Consortia Name Address Website
Preble County Schools Regional Council of
Governments
597 Hillcrest Dr. Eaton, OHIO 45320-1793
Putnam County School Consortium
124 Putnam Parkway
Ottawa, OH 45875
http://putnam.noacsc.org/
Ross County School Employees Insurance
Consortium
475 Western Avenue, Suite E, Chillicothe, Ohio 45601 http://www.rpesd.org/
Shelby County Schools Health Insurance Shelby County, Ohio
Van Wert Area Schools Insurance Group
(VWAISG)
205 West Crawford Street
Van Wert, Ohio 45891
Wood County School Consortium Wood County, Ohio
Wyandot Crawford Health Benefit Wyandot County, Ohio
Source: 2014 and 2015 SERB Insurance Survey datasets. Address and website information was retrieved from the 2014/2015 SERB Insurance Survey
datasets, consortium websites, and from independent audits of the consortia conducted by the Ohio Auditor of State.

51
Appendix B: Glossary of Key Terms and Concepts
This Glossary of key terms and concepts is intended to assist users of this document in understanding
the terms used and concepts conveyed in this document. It is not intended to represent a
comprehensive listing of terms used in the insurance industry or in the ACA legislation. Readers looking
for further information may want to consult the reference sources listed at the end of this Glossary.
A
Actual Charge:
“The dollar amount a health care provider bills for a particular medical service or procedure” (ODI:
Healthcare Reform Website Glossary, 2015).
Administrative Costs:
“Costs related to activities such as utilization review, marketing, medical underwriting and claims
processing” (ODI: Healthcare Reform Website Glossary, 2015).
Adverse Selection:
“Among applicants for a given group or individual health insurance program, the tendency for those
with an impaired health status or those prone to higher-than-average benefits usage, to be enrolled in
disproportionate numbers in lower deductible plans” (ODI: Healthcare Reform Website Glossary,
2015).
Affordable Care Act (ACA):
The ACA is a shorthand term for the “Patient Protection and Affordable Care Act (PPACA)”, a piece of
legislation signed into law on March 23, 2010 by President Barak Obama. This legislation outlines
adjustments and enhancements to health plan structures, including but not limited to defining
comprehensive coverage guidelines, expanding coverage for individuals and is intended to reduce
health care spending in the US. (HealthCare.gov: Glossary, 2015) [in this Resource Guide, we also use
this term as an umbrella term covering not only the PPACA, but also the “Health Care and Educational
Reconciliation Act of 2010” which passed and signed shortly after the PPACA.]

52
“Affordable Coverage”:
“Employer coverage is considered affordable - as it relates to the premium tax credit - if the
employee’s share of the annual premium for the lowest priced self-only plan is no greater than 9.56%
of that single individual’s annual household income. People offered employer-sponsored coverage
that’s affordable and provides minimum value, are not eligible for a premium tax credit”
(HealthCare.gov: Glossary, 2015).
Agent:
A “licensed salesperson that represents one or more health insurance companies and presents their
products to consumers” (ODI: Healthcare Reform Website Guide, 2015).
Allowable Costs:
“Charges for services rendered or supplies furnished by a health provider which qualifies as covered
expenses for insurance purposes” (ODI: Healthcare Reform Website Glossary, 2015).
Annual Limits
“The PPACA bans annual dollar limits that job related plans and individual health insurance plans can
put on most covered health benefits. Before the health care law, many health plans set an annual limit
– a dollar limit on their yearly spending for covered benefits. One was required to pay the cost of all
care exceeding those limits”. Two exceptions to annual limits are that plans can put an annual dollar
limit and a lifetime dollar limit on spending for health care services that are not considered essential
health benefits. Secondly, grandfathered individual health insurance policies are not required to follow
the rules on annual limits. (DHHS, 2015)
Attachment Point:
This number represents the overall limit of claim liability for the group (employer). Beyond this point
the stop loss policy compensates the group at the end of the contract period (Wans, 1991).

53
B
Beneficiary:
“This is a person who receives benefits of any insurance plan or policy” (ODI: Healthcare Reform
Website Guide, 2015).
Benefit:
”The amount payable by the insurance company to a claimant, assignees or beneficiary when the
insured suffers a loss” (ODI: Healthcare Reform Website Guide, 2015).
Benefit Maximum:
“The most a health insurance policy will pay for a specified loss or covered service. Benefits may be
paid to the policy holder or a third party” (ODI: Healthcare Reform Website Guide, 2015).
Benefit Period:
“The period when services are covered under your plan and also when benefit payments from an
insurance policy are available such as: maximums, deductibles and coinsurance limits accumulate”
(ODI: Healthcare Reform Website Guide, 2015).
Broker:
See “Agent.”

54
C
Cadillac Tax:
A 40% excise tax assessed on high premium health plans that offer rich benefits exceeding more than
$10,200 (single) or $27,500 (family) annually). This penalty is not in effect until 2020 and is subject to
change and is only accurate as far as the date of this document production (Blue Cross Blue Shield:
New Health Care Reform Fees , 2015).
Carrier:
“The insurance company or Health Maintenance Organization (HMO) offering a health plan” (ODI:
Healthcare Reform Website Guide, 2015).
Cash Reserve:
A portion of the premium retained to pay future claims (NAIC): Glossary of Insurance Terminology,
2015).
Claims:
“A request for payment for services provided by a health care professional” (ODI: Healthcare Reform
Co-insurance:
“Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of
the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if
the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your
deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest
of the allowed amount” (HealthCare.gov: Glossary, 2015)

55
Community rating:
This is a way of pricing insurance, where every policyholder pays the same premium, regardless of
health status, age or other factors (ODI: Healthcare Reform Website Guide, 2015).
Co-payment (co-insurance):
“A fixed amount (for example, $15) you pay for a covered health care service, usually when you get the
service. The amount can vary by the type of covered health care service”. (HealthCare.gov: Glossary,
2015)
Coverage:
”All or part of an individual’s health care costs, paid either by insurance or by the government” (ODI:
Covered Services:
“These are services for which an insurance policy will pay” (ODI: Healthcare Reform Website Guide,
2015).
D
Deductible:
The amount an individual must pay for health care expenses before insurance (or self-insured health
plan) covers the cost (ODI). For instance, a plan deductible of $1,500 means that the enrollee will pay
100% of any medical or pharmaceutical expenses until the costs have exceeded the $1,500(deductible)
at which you will share the costs with your plan through co-insurance or co-pays (ODI: Healthcare
Reform Website Guide, 2015).

56
Dependents:
Spouse and/or unmarried, dependent children (whether natural, adopted or step up to age 26) of an
insured (ODI: Healthcare Reform Website Guide, 2015).
Dividend:
A refund of a portion of the premium paid by the insured from insurer surplus This is a portion of the
corporate earnings and may be paid a certain number of times each year (like each quarter) (NAIC:
Glossary of Insurance Terminology, 2015).
E
Economies of Scale:
“The cost advantage that arises with increased output of a product. Economies of scale arise because
of the inverse relationship between the quantity produced and per-unit fixed costs; i.e. the greater the
quantity of a good produced, the lower the per-unit fixed cost because these costs are shared over a
larger number of goods”(Investopedia: Economies of Scale Definition, 2003).
Effective Date:
“The date your insurance is to begin. You are not covered until the policy’s effective date” (ODI:
Employer Shared Responsibility Provisions (i.e. Employer Mandate):
The Employer Shared Responsibility provisions under section 4980H of the Internal Revenue Code
(added to the Code by the ACA) state that in year 2015 and after, employers employing at least a
certain number of employees (50 full-time employees or 50 full-time equivalent employees) will be
subject to the Employer Shared Responsibility provisions under section 4980H of the Internal Revenue
Code, which defines penalties for employers not providing adequate health benefits for their
employees. As defined by the statute, a full-time employee is an individual employed on average at
least 30 hours of service per week. As defined by the statute, a full-time employee is an individual
employed on average at least 30 hours of service per week. An employer that meets the 50 full-time

57
employee threshold is referred to as an applicable large employer. (IRS: Shared Responsibility
Provision, 2015). *For information on penalties please refer to “Pay or Play Penalties.”
Employee Retirement Income Security Act (ERISA):
ERISA is a federal law that sets minimum standards for most voluntarily established pension and health
plans in private industry to provide protection for individuals in these plans. ERISA does not cover
retirement plans established or maintained by governmental entities (DOL: Health Benefits Advisor-
Glossary, 2015).
Essential (Health) Benefits:
“The PPACA requires all health insurance plans sold after 2014 to include a basic package of benefits
including hospitalization, outpatient services, maternity care, prescription drugs, emergency care and
preventive services among other benefits” (Healthcare.gov: Essential Health Benefits, 2015).
These health benefits must include items and services within at least the following 10 categories:
ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental
health and substance use disorder services, including behavioral health treatment; prescription drugs;
rehabilitative services and devices; laboratory services; preventive and wellness services and chronic
disease management; and pediatric services, including oral and vision care (HealthCare.gov: Glossary,
2015).
Exchange User Fee:
The federally-facilitated exchange user fee helps to fund and support federal exchanges. Health
insurance carriers are charged 3.5% of their premium for all business on a federal exchange starting in
2014. This fee only impacts non-grandfathered health plans (Medical Mutual: Healthcare Reform Costs
and Fees, 2015).

58
Experience Rating:
“A system where an insurance company evaluates the risk of an individual or group by looking at the
applicant’s health history “(ODI: Healthcare Reform Website Guide, 2015).
Explanation of Benefits (EOB):
”A statement from an insurance company showing which payments have been made on a claim” (ODI:
F
Fee for Service:
“Traditional insurance that does not place restrictions on which doctors you can use” (ODI: Healthcare
Fully-Insured Plans:
This is a health plan where an employer group contracts with a health care carrier to provide health
insurance coverage to its employees and their dependents. The carrier underwrites and administers
the health plan, and also pays the covered claims (Cigna: Glossary of Health Care and Health Insurance
Terms, 2015).
Full-Time Employee:
An employee who works an average of at least 30 hours per week or on average 130 hours per month

59
Full-Time Equivalent Employee (FTE):
Full-time equivalent employees are calculated based upon a combination of full time and part time
employees. Employees scheduled to work 20 hours per week are counted as 0.5 FTEs. The formula
looks like this: Employee’s scheduled hours divided by employer’s hours for a full-time (FT) workweek.
Another way of stating the formula is: hours scheduled ÷ FT hours. Using this formula, two employees
who work 20 hours per week is 40 ÷ 40 = 1.0 FTE (Society for Human Resource Management [SHRM]:
How Employers Calculate Full-Time Equivalent employees, 2015).
G
Grandfathered Plans:
“Grandfathered plans are those that were in existence on March 23, 2010 and have not been changed
in ways that substantially cut benefits or increase costs for consumers” (HealthCare.gov: Glossary,
2015).
Group health plan:
“An employee welfare benefit plan that is established or maintained by an employer or by an
employee organization (such as a union), or both, that provides medical care for participants or their
dependents directly or through insurance, reimbursement or otherwise” (ODI: Healthcare Reform
H
Health Insurance Consortium:
“A group of similar businesses or organizations that join together to provide insurance coverage”
(Investopedia, 2015). In this document, we use the term “Health Benefit Consortium” as a synonym
for this term.

60
Health Benefit Consortium:
See “Health Insurance Consortium”.
I
Incurred Claims:
These are paid claims plus amounts held in reserve for those that have been incurred but not yet paid
(NAIC: Glossary of Insurance Terminology, 2015).
In-Network:
“This is providers or health care facilities that are a part of a health plan’s network of providers with
insured individuals paying less with an in-network provider” (ODI: Healthcare Reform Website Guide,
2015).
In-Network Copayment:
“A fixed amount you pay for covered health care services to providers who contract with your health
insurance or plan. In-network copayments usually are less than out-of-network copayments”
J
Joint Insurance Purchasing Arrangement:
See “Health Insurance Consortium.”

61
L
Large Group Employer (for Employer Shared Responsibility Provisions):
A large group employer is defined by having 50 or more full-time employees or equivalents. (IRS:
Affordable Care Act Tax Provisions for Employers, 2015).
Loss Reserve:
“The amount that insurers set aside to cover claims incurred but not yet paid” (NAIC: Glossary of
Insurance Terminology, 2015).
M
Market Share Fee (also referred to as “Health Insurer Fee”):
“The market share fee, referred to as the annual fee on health insurance providers in the PPACA
regulations, is based on each carrier’s market share of net annual health insurance premiums
collected. This permanent fee is effective beginning in 2014. The fee will fund premium tax subsidies
for low income individuals and families purchasing insurance through the public exchanges. After
2018, the fee will increase in proportion to overall premium growth” (Medical Mutual: Fees and Taxes
in Healthcare Reform, 2013).
Maximum Dollar Limit:
“The maximum amount of money that an insurance company (or self-funded company) will pay for
claims within a set time period” (ODI: Healthcare Reform Website Guide, 2015).
Medical Loss Ratio:
“The percentage of premium dollars an insurance company spends on medical care, as opposed to
administrative costs or profits. For instance, a medical loss ratio of 80% indicates that the insurer is
using the remaining 20% to pay overhead expenses, such as administrative costs” (ODI: Health Reform
Glossary, 2015).

62
Medical Underwriting:
“A process used by insurance companies to try to figure out your health status when you're applying
for health insurance coverage to determine whether to offer you coverage, at what price, and with
what exclusions or limits” (Healthcare.gov: Glossary, 2015).
Minimum Essential Coverage (MEC):
“The type of coverage an individual needs to have to meet the individual responsibility requirement
under the Affordable Care Act” (HealthCare.gov: Glossary, 2015).
Minimum Value:
“A health plan meets this standard if it’s designed to pay at least 60% of the total cost of medical
services for a standard population” (HealthCare.gov: Glossary, 2015).
N
Network:
“The facilities, providers and suppliers your health insurer or plan has contracted with to provide
health care services” (HealthCare.gov: Glossary, 2015).
O
Open Enrollment Period:
“This is a period in which individuals may enroll for an insurance policy” (ODI: Healthcare Reform

63
Out-of-Network Provider:
A health care provider (such as a hospital or doctor) that is not contracted to be part of a managed
care organization’s network (such as a Health Maintenance Organization or Preferred Provider
Organization). Depending on the managed care organization’s rules, an individual may not be covered
at all or may be required to pay a higher proportion of the total costs when he/she seeks care from an
out-of-network provider (ODI: Healthcare Reform Website Guide, 2015).
Out-of-Pocket Maximum:
A predetermined limited amount of money that the individual must pay themselves before an
insurance company or self-funded health company will pay 100% for an individual’s health care
expenses (ODI: Healthcare Reform Website Guide, 2015).
P
Patient Centered Outcome Research Institute (PCORI) Fee:
“This fee funds research that evaluates and compares health outcomes, clinical effectiveness, risks and
benefits of medical treatments and services. The research will help patients, health care professionals
and policymakers make better informed decisions about treatment options” (Blue Cross Blue Shield:
New Health Care Reform Fees, 2015).
The Patient Protection and Affordable Care Act (PPACA):
The Patient Protection and Affordable Care Act (PPACA) is a piece of health care legislation that was
signed into law on March 23, 2010 by President Barack Obama (HealthCare.gov: Glossary, 2015).
Please refer to ACA for further information.
“Pay or Play” Penalties:
“Under the "shared responsibility" provision of the Patient Protection and Affordable Care Act
(PPACA), beginning in 2014 employers with 50 or more full-time employees (FTEs) working 30 or more
hours per week (including the sum of hours by part-time workers that added together equal
"equivalent" full-time workers) will face penalties if they do not offer FTEs "affordable" insurance.

64
Large employers that do not offer coverage to their full-time employees, they face a penalty of $2,000
times the total number of full time employees if at least one full time employee receives a tax credit to
purchase coverage through a government-run health insurance exchange established under the
PPACA. However, the $2,000-per-full time employee penalty will not apply so long as employers offer
coverage to at least 95 percent of their full-time employees and their dependent children up to age 26.
Large employers that do offer coverage to their full-time employees (and dependent children up to age
26), but the coverage is “unaffordable” to certain employees or does not provide minimum value, will
face a penalty of $3,000 times the number of FTEs receiving tax credits for exchange coverage (not to
exceed $2,000 times the total number of FTEs).” (SHRM, 2015)
Premium:
“The amount that must be paid for your health insurance or plan; which can be paid monthly, quarterly
or yearly” (HealthCare.gov: Glossary, 2015).
Public Entity:
“A public entity means the state (of Ohio) or any political subdivision of the state located entirely
within the state, including, without limitation, any municipal corporation; county; township; school
district; governing authority of a community school district established under Chapter 3314 of the Ohio
Revised Code; college preparatory boarding school established under Chapter 3328 of the Ohio
Revised Code or its operator; state institution of higher learning; public or special district; state agency,
authority, commission, or board; or other branch of public employment” (ORC: Chapter 4117, 2015).
This definition is derived from language defining “public employer” as found in ORC Chapter 4117.
R
Rating:
The process of evaluating, or underwriting, a group or an individual to figure out a health insurance
premium rate in relation to the risk the health insurance company takes to cover health care of the
person or group. Key components of the rating formula include age, sex, location, and how many
benefits the plan includes (AARP, 2015).

65
Reinsurance Fee:
See “Transitional Reinsurance Fee”
Risk:
“The chance, probability or amount of possible loss to the insurance company” (ODI: Healthcare
Risk Adjustment User Fee:
“Health insurers will be assessed an annual risk adjustment user fee on all individual and small group
policies that are compliant with the new ACA underwriting restrictions. The fee is to fund the
government’s cost to administer the Risk Adjustment Program.” (Medical Mutual: Fees and Taxes in
Healthcare Reform 2013).”The Risk Adjustment program is designed to help stabilize both the
individual and small group insurance marketplaces. The program assists insurance carriers covering
high-risk individual and small group members” (Medical Mutual: Federally Mandated Fees for
Employers, 2015).
Risk Pooling:
See “Health Insurance Consortium.”
S
Self-Insured Plan:
“An organization (usually an employer) that pays for health care costs out of the organizations own
pocket” (ODI: Healthcare Reform Website Guide, 2015).
Self-Insurance:
The method of providing employee benefits in which the group purchases no insurance at all, thereby
assuming full responsibility for the claims (Wans, 1991).

66
Small Group Employer (for Community Rating Provisions):
The Protecting Affordable Coverage for Employees Act defines small group employers as those with 1 -
50 employees. States may define small employers as having one to 100 full-time employees (PACE,
2015).
Stop-Loss:
“The dollar amount of claims filed for eligible expenses at which you have paid 100% of your out-of-
pocket expense and then the insurance company will begin to pay 100% of the costs. Stop-loss is
reached when an insured individual has paid the deductible and reached the out-of-pocket maximum
amount of co-insurance” (ODI: Healthcare Reform Website Guide, 2015).
Stop-Loss Insurance:
Stop-loss insurance (also known as excess insurance) is a product that provides protection for self-
insured employers by serving as a reimbursement mechanism for catastrophic claims exceeding pre-
determined levels (Self Insurance Institute of America, accessed on June 25, 2016 via
http://www.siia.org/i4a/pages/Index.cfm?pageID=4549).
T
Third Party Administrator:
“A person or organization that manages the payment, processing and settlement of life, health, dental,
disability and self-insurance claims for an organization” (ODI: Healthcare Reform Website Guide, 2015).
Transitional Reinsurance Fee:
The Transitional Reinsurance Fee is an annual fee on fully-insured and self-funded health plans from
2014-2016. The transitional reinsurance program will collect contributions from contributing entities
to fund reinsurance payments to issuers of non-grandfathered reinsurance-eligible individual market
plans, the administrative costs of operating the reinsurance program, and the General Fund of the U.S.

67
Treasury for the 2014, 2015 and 2016 benefit years (CMS: The Transitional Reinsurance Program,
2014). The amount of the fee changes per year and is charged on a Per Member Per Year (PMPY) basis.
The amount due for year 2014 is $63 PMPY, the due in year 2015 is $44 PMPY, and the amount due in
year 2016 is $27 PMPY (Cigna: Fees and Taxes, 2015).
References for Glossary Terms
AARP: Health Insurance Terms Glossary. (2015). Retrieved June 9, 2015, from
http://www.aarphealthcare.com/tools-and-resources/health-insurance-terms-glossary.html
Blue Cross Blue Shield: New Health Care Reform Fees. (2015). Retrieved June 9, 2015, from
http://www3.bcbsfl.com/wps/wcm/connect/4ccb85804f1d7db0af2cbf77b76dbd01/HCR+New+
Fees+BA+Flyer+76576.pdf?MOD=AJPERES&CACHEID=4ccb85804f1d7db0af2cbf77b76dbd01
Bureau of Labor Statistics (BLS): Definitions of Health Insurance Terms. (2015). Retrieved June 10,
2015, from
http://www.bls.gov/ncs/ebs/sp/healthterms.pdf
Centers for Medicare & Medicaid Services (CMS): The Transitional Reinsurance Program - Reinsurance
Contributions. (2014). Retrieved June 15, 2015, from
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/The-
Transitional-Reinsurance-Program/Reinsurance-Contributions.html
Cigna: Fees and Taxes. (2015). Retrieved June 25, 2015, from
http://www.cigna.com/health-care-reform/fees-and-taxes

68
Cigna: Glossary of Health Care and Health Insurance Terms. (2015). Retrieved June 25, 2015, from
http://www.cigna.com/glossary
CMS: Glossary of Health Coverage and Medical Terms (2015). Centers for Medicare & Medicaid
Services (CMS). Retrieved June 8, 2015, from
https://www.cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf
Department of Health and Human Services (DHHS): Lifetime & Annual Limits. (2015). Retrieved June
25, 2015, from
http://www.hhs.gov/healthcare/rights/limits/
Department of Labor (DOL): Health Benefits Advisor-Glossary. (2015). Retrieved June 10, 2015, from
http://www.dol.gov/elaws/ebsa/health/4.asp
HealthCare.gov: Glossary. (2015). Retrieved June 8, 2015, from https://www.healthcare.gov/glossary/
Insurance Consortium Definition | Investopedia. (2015, May 12). Retrieved June 8, 2015, from
http://www.investopedia.com/terms/i/insurance-consortium.asp
Internal Revenue Service (IRS): Affordable Care Act Tax Provisions for Employers. (2015). Retrieved
June 9, 2015, from
http://www.irs.gov/Affordable-Care-Act/Employers
Internal Revenue Service (IRS): Shared Responsibility Provisions. (2015). Retrieved June 25, 2015, from
http://www.irs.gov/Affordable-Care-Act/Employers/Questions-and-Answers-on-Employer-

69
Shared-Responsibility-Provisions-Under-the-Affordable-Care-Act
Investopedia: Economies Of Scale Definition (2003).Retrieved June 11, 2015, from
http://www.investopedia.com/terms/e/economiesofscale.asp
Medical Mutual: Good to Know Health Insurance Terms. (2015). Retrieved June 8, 2015, from
https://www.medmutual.com/For-Individuals-and-Families/Health-Insurance-
Education/Glossary-of-Terms.aspx
Medical Mutual: Federally Mandated Fees for Employers. (2015). Retrieved October 13, 2015, from
https://www.medmutual.com/Healthcare-Reform/Reform-for-Employers/Federally-Mandated-
Fees-Impacting-Employers.aspx
Medical Mutual: Fees and Taxes in Healthcare Reform. (2013) Retrieved May 21, 2015, from
https://www.medmutual.com/~/media/Files/Healthcare%20Reform%20PDFs/Final%20Taxes%
20and%20Fees%20Presentation%20March%202013.ashx
National Association of Insurance Commissioners (NAIC): Glossary of Insurance Terminology. (2015).
Retrieved June 8, 2015, from
http://www.naic.org/consumer_glossary.htm
Ohio Department of Insurance (ODI): Healthcare Reform Website Glossary (2015). Ohio Department of
Insurance. Retrieved from
http://www.insurance.ohio.gov/documents/HealthcareGlossary.pdf

70
Ohio Revised Code (ORC): Chapter 4117: Public Employees' Collective Bargaining. (2015). Retrieved
October 13, 2015, from
Self-Insurance Institute of America (SIIA): Stop Loss Excess Insurance. (2016). Retrieved June 25, 2016
from
http://www.siia.org/i4a/pages/Index.cfm?pageID=4549
Society for Human Resource Management (SHRM) : Eligibility: How Employers Calculate Full-Time
Equivalent employees. (2015). Retrieved June 10, 2015, from
http://www.shrm.org/templatestools/hrqa/pages/calculateftehours.aspx
Society for Human Resource Management (SHRM) : Making the ‘Pay to Play’ Decision. (2015).
Retrieved June 18, 2015, from
http://www.shrm.org/hrdisciplines/benefits/articles/pages/play-pay-decision.aspx
Wans, Joyce (1991). Stop Loss 101: Self-Insurance for Employee Benefits. Duncanson & Holt Group.

71
Appendix C: The Research and Information Development Approaches Used to Create
This Resource Guide
Introduction
Since the beginning of 2015, the Center for Public Policy and Health at Kent State University (KSU-
CPPH) has undertaken multiple activities to produce the information contained in this Resource Guide.
These activities include:
- building a project team with experience and expertise in subject matters relevant to this Guide;
- consulting with key professionals in professions relevant to the subject matters in this Guide;
- searching professional and scholarly literatures associated with health benefit consortia, the
changing nature of the US health insurance market, ACA implementation, and “best practices”
for purchasing health benefit plans;
- obtaining and analyzing survey data on health benefit plan choices of larger public entities in
Ohio obtained from surveys conducted by the State Employment Relations Board (SERB);
- conducting targeted research in key areas, including Collective Bargaining Agreements (CBA’s)
between unions and public sector entities in Ohio, the practices of health benefit consortia in
Ohio, and the practices and views of smaller public entities in Ohio on health benefits for their
employees, and;
- incorporating feedback from State of Ohio officials relevant to this guide and updating the
guide to reflect federal legislative changes occurring between Fall of 2015 and Spring of 2016.
Information and insights gained through these efforts have been used to produce this Resource Guide
for public entities in Ohio. In the paragraphs that follow, we summarize our approaches to carrying out
these activities.
Project Team Experience and Expertise
Our project team includes individuals with experience in collaborative governance, local government
administration, health insurance practices, and data analysis and research. Dr. John Hoornbeek has
provided overall leadership for the project, and he brings background and expertise in health policy
and management, collaborative endeavors among public entities in Ohio, and public policy research
and analysis. Dr. Thomas Pascarella brings decades of local government administration experience to
the project, as well as expertise in local government collaboration and local government health
benefits administration. Ms. Heather Mikulski, a former Client Manager at a local Third Party
Administrator and doctoral student in Public Health at KSU, brings a decade and a half of health
insurance experience to the project, and – over the last several years – her work has been affected by
implementation of the ACA. She has provided input and guidance on aspects of the project dealing
with health insurance practices and implementation of the ACA. Her experience with the ACA has
been supplemented by the experiences of Dr. Pascarella, who has been evaluating the impacts of the
ACA on health benefits in the City of Tallmadge, Ohio, where he serves as Director of Administration.
Mr. Matthew Stefanak, a former Health Commissioner from Mahoning County, Ohio, has brought
additional experience in local government administration and health policy to the project. Dr. Kimberly

72
Laurene and Dr. Rebecca Fischbein have brought experience in data and statistical analysis to the
project. And Mr. Joshua Filla supplements the expertise above with experience in working on issues
associated with local government administration, public sector collaboration, and public health service
provision in Ohio. Ms. Kathryn Bland and Ms. Marissa Bland – Masters of Public Health students at KSU
-- have also applied their educational backgrounds and experiences to the development of this
Resource Guide. Dr. Willie Oglesby, who has taught a graduate level seminar on ACA implementation
at KSU, also reviewed and provided input on key portions of this Resource Guide.
Consultations with External Professionals
In gathering information to develop this Resource Guide, we have also contacted and benefited from
ideas and guidance provided by professionals from a number of different organizations. Through
contacts made available by ODAS, we contacted and sought insights from professionals with years of
experience in the health insurance industry in Ohio. We have also consulted with officials associated
with health benefit plan consortia in Ohio, and they have provided valuable information on the
prevalence and practices of health benefit plan consortia. In addition, we have sought out and
benefited from perspectives offered by public entity officials with responsibilities relating to health
benefit administration, as well as officials from government agencies with expertise and/or
responsibilities relating to health benefit regulation, ACA implementation, and the collection of
information on health plan choices and administration in Ohio. The agencies consulted include the
United States Department of Health and Human Services, the Ohio Department of Insurance
Regulation, and the State Employment Relations Board of Ohio.
Searches of Relevant Literature
Members of the project team also conducted literature searches for information on a range of subject
matters relevant to the information provided in this Resource Guide. In so doing, they sought out and
reviewed information from both professional and scholarly sources. The literature searches focused
on health benefit consortia and their use and impacts on the cost and nature of health plan benefits,
health benefit planning and practices associated with public entities, the changing health insurance
market and ACA implementation, the roles of labor unions in health benefit plan selection and
management, and “best practices” for selection of health benefit plans. Selected materials from these
reviews of literature are included in the Reference section for this document and in Appendix D.
Review and Analysis of State Employment Relations Board (SERB) Data
Each year, the State Employment Relations Board (SERB) of Ohio conducts a survey of public entities in
Ohio that serve populations of more than 5,000 people. About 1800 public entities in the state are
surveyed regarding their health insurance choices and benefits. While the survey includes information
on many aspects of health insurance benefits provided to public employees and their families, it also
includes information on the use of health benefit plan consortia.
In December 2014 and early 2015, the project team visited with the staff of the SERB and they
provided a report on the findings of their 2014 SERB survey (SERB, 2015) as well as the data set
underlying it. Both the report and the data set have been reviewed and analyzed in various ways, and
this work with the SERB collected survey data has informed this Research Guide. The focus with

73
respect to this information has been on the use of health benefit consortia, and the costs and benefits
associated with health benefit plans in Ohio. Results flowing from these analyses of SERB data inform
this Resource Guide and the information it provides on the use of various kinds of health benefit plans
by differing types of entities.
The results gleaned from the SERB data also enable a foundation for bi-variate quantitative analyses
comparing the costs and benefits of public entity health plans that are purchased individually and
jointly, as well as additional analyses comparing fully-insured and self-funded health plans. These
analyses are presented in the companion resource document to this Resource Guide, Adapting to the
Changing Health Insurance Landscape: A Look at the Use and Effects of Health Benefit Consortia by
Public Entities in Ohio. This report was completed concurrently with this Resource Guide and can be
accessed through the Ohio Department of Administrative Services and the KSU-CPPH.
Project team members also met with the SERB staff regarding the 2015 survey, and – as a result – the
SERB staff included some additional questions on health benefit consortia in their 2015 survey. In the
Spring of 2015, data on the responses to these additional questions became available, and information
from those responses is also included in this Resource Guide.
Targeted Supplemental Research
The project team supplemented the information gained through the activities above with several other
targeted research efforts. These research efforts are described briefly below.
Analysis of Collective Bargaining Agreements (CBAs) & their Implications for Health Benefit Plans
A key issue for a number of public entities seeking to make changes in their health benefit plans relates
to the provisions of their CBA’s and their impacts on the ability of public entity officials to make
changes in health plans. In some cases, collective bargaining agreements may restrict the ability of
public officials to make changes in the health plans serving their employees. To gain a better sense of
the extent to which this is the case, members of the project team reviewed a sample of 285 collective
bargaining agreements obtained through the SERB’s electronic dataset of these agreements to
ascertain the prescribed roles of unions, employees, and public entity managers in approving or
advising on health benefits plans affecting them. This review provided insights on the constraints and
opportunities associated with CBA provisions relating to the health benefit plans of public entities in
Ohio. Information from these reviews has been incorporated into the Resource Guide where
appropriate. Readers interested in these reviews may contact the KSU-CPPH.
Survey of Health Benefit Consortium Officials
Through the SERB dataset and other means, the project team was able to compile a list of 53 health
benefit consortia providing services to public entities in Ohio. To improve our understanding of both
the number and nature of health benefit plan consortia operating in Ohio, the project team developed
an interview protocol and survey instrument, and sought appropriate review by the Kent State
University Institutional Review Board (IRB). It then administered interviews and a follow up survey to
health benefit consortia officials throughout Ohio. Through the interviews and follow up surveys, the

74
team consulted with officials from 36 of the 54 consortia known to be operating in the state at that
time.14
Through these efforts, the project team identified fully operating health benefit consortia in Ohio and
gained information on the types of public entities they served. Consortium officials who responded to
the project team’s inquiries and consented to having their names and contact information included in
the Resource Guide are listed in the Appendix A-1 of this Resource Guide. Appendix A-2 includes
baseline information on other health benefit consortia that were reported to SERB. However, because
the project team was not successful in communicating directly with officials from this latter group of
consortia during the Summer of 2015, the information provided on these consortia is limited to their
reported names and whatever location information we could obtain from external sources.
Information from the interviews and follow up surveys of consortia are included in the Resource Guide,
and has been used as one source of information to support development of the steps and/or
considerations outlined in this Resource Guide.
Interviews with Officials from Smaller Local Governments
While the SERB data sets and reports are tremendously helpful in understanding health benefit choices
made by public entities in Ohio, the data contained in them are biased toward larger public entities
and school districts, both of which are over-sampled in comparison to their distribution across the
more than 3500 public entities in the state. For this reason, the project team conducted brief
interviews with a small sample of local officials affiliated with local jurisdictions that serve less than
5,000 people within the state to learn more about their health benefits practices and interests and
concerns in this area. The information gained through these interviews is used to help assure – to the
extent possible, given available time and resources -- that key elements of the Resource Guide are
applicable to this portion of the population of public entities in Ohio.
Updating the Guide Based on Sponsor Feedback and to Account for Recent Federal Policy Changes
After receiving useful feedback from State of Ohio officials, the project team investigated federal
legislative changes relevant to the implementation of the ACA that were enacted between October of
2015 and May of 2016. Based on the feedback received and further investigations of recent federal
legislative changes, the project team updated this guide. At this time, the project team also made a
final review of the document to identify and make appropriate adjustments in presentation of the
material offered in the guide.
14
During the data collection phase of this project there were 54 consortia identified through the SERB dataset.
However, after the data collection and analysis took place one consortium merged with another resulting in a
final total of known consortia operating in Ohio of 53. However, we do report a survey universe of 54 consortia
here as the merger did not occur until after data collection and analysis were complete. In addition, the
Appendix A-1 compilation process used to compile the consortium information presented in Appendix A-1 relied
heavily on the phone interview component of the data collection process mentioned above, and as a result,
there may be ambiguities between the information presented in Appendix A-1 and the survey results. We did
not attempt to address those ambiguities specifically as we analyzed the data, and treated the Appendix A-1
information collection and the survey data analyses as two separate processes.

75
Through the activities described above, the project team learned a great deal about the changing
health insurance market, the health benefit purchasing practices of public entities, the public sector
health benefit consortium business in Ohio, and opportunities for public entities to make appropriate
health benefit choices in a changing health insurance market. Our learnings are documented in this
Resource Guide and its companion document, Adapting to the Changing Health Insurance Landscape: A
Look at the Use and Effects of Health Benefit Consortia by Public Entities in Ohio.
Appendix D: Supplemental Readings
Consortia:
Bender, K., & Fritchen, B. (2008). Government-8 Sponsored Health Insurance Purchasing
Arrangements: Do They Reduce Costs or Expand Coverage for Individuals and Small Employers?.
Prepared for the Blue Cross and Blue Shield Association.
Christianson, J. B., & Feldman, R. (2002). Evolution in the buyers health care action group purchasing
initiative. Health Affairs, 21(1), 76-88.
Cutis, R. & Neuschler, E. (2009). What Health Insurance Exchanges or Choice Pools Can and Can’t Do
About Risks and Costs. Retrieved from:
http://www.ihps.org/pubs/WhatHealthInsuranceExchangesorChoicePoolsCanandantDoAboutRisksand
Costs.pdf
New York School Boards Association. (NYSSBA) (2009). Can Health Insurance Consortiums Rein in
School District Health care Costs?(2009,September 1).Retrieved January 20, 2015,
fromhttp://www.nyssba.org/clientuploads/nyssba_pdf/ConsortiumReportFinal.pdf

76
Health Insurance Decision Making
Agency for Healthcare Research and Quality (AHRQ) (1997). Theory and Reality of Value-Based
Purchasing: Lessons from the Pioneer. Retrieved June 25, 2015 from
http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/meyer/index.html
Brown, J. (2013). Health Reform Road Map for Cities and Villages. Retrieved from
http://www.omlohio.org/healthreform/HealthReform%20-%20Final.pdf
Mercer Health and Benefits (2006). Managing the Costs of Health Care Coverage: Emerging Practices
among Public-Sector Employers. Retrieved from http://www.zanebenefits.com/blog/best-practices-
defined-contribution-health-plans
Self Insurance Educational Foundation, Inc (no date). Understanding Self-Insured Group Health Plans:
Solutions for Containing Cost While Providing Quality Benefits. Retrieved June 25, 2015 from
http://www.hcc.com/portals/0/subsites/hcclife/downloads/HealthCareSuccessPublicationl.pdf

77
Public Entities:
Bell, A. (2014). Small groups may be hit by PPACA rule. Retrieved May 18, 2015, from
http://www.benefitspro.com/2014/02/24/small-groups-may-be-hit-by-ppaca-rule
Brown, J. (2013). Health Reform Road Map for Cities and Villages. Retrieved from
http://www.omlohio.org/healthreform/HealthReform%20-%20Final.pdf
Internal Revenue Service. (2014). IRS: Questions and Answers on Employer Shared Responsibility
Provisions Under the Affordable Care Act. (2014, December 15). Retrieved January 13, 2015, from
http://www.irs.gov/Affordable-Care-Act/Employers/Questions-and-Answers-onEmployer-Shared-
Responsibility-Provisions-Under-the-Affordable-Care-Act
Kaiser Family Foundation (2015). State Health Facts. Retrieved May 19, 2015, from
http://kff.org/statedata/
The Henry J. Kaiser Family Foundation. (2013). Average Employee-Plus-One Premium per Enrolled
Employee For Employer-Based Health Insurance. Retrieved June 24, 2015,from
http://kff.org/other/state-indicator/employee-plus-one-coverage/
U.S. Small Business Association (U.S. SBA) (2015). Employers with 50 or More Employees. Retrieved
January 13, 2015, from https://www.sba.gov/content/employers50-or-more-employees
Insurance Information:
Barro, J. (2011). Cadillac coverage: the high cost of public employee health benefits.
CivicReport,(Center for state and Local Leadership, The Manhattan Institute No. 65.)
Cadillac Tax Fact Sheet. (2015). Retrieved May 21, 2015,
fromhttp://www.cigna.com/assets/docs/about-cigna/informed-on-reform/cadillac-taxfact-sheet.pdf

78
CMS: Centers for Medicare and Medicaid Services (2013). Overview: Final Rule for Health Insurance
Market Reforms. Retrieved March 31, 2015,from
https://www.cms.gov/CCIIO/Resources/Files/Downloads/market-rulestechnical-summary 2-27-
2013.pdf
CMS: Centers for Medicare and Medicaid Services (2015). Center for Consumer Information&
Insurance Oversight: The Transitional Reinsurance Program. Retrieved May 18, 2015 from
https://www.cms.gov/CCIIO/Programs-and-Initiatives/PremiumStabilization-
Programs/TheTransitional-Reinsurance-Program/Reinsurance Contributions.html
Kaiser Family Foundation (2015a). Explaining Health Care Reform: Risk Adjustment, Reinsurance and
Risk Corridors. (2015). Retrieved May 26, 2015, from http://kff.org/health-reform/issue-
brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/
Ohio Revised Code (ORC; 2015) – ORC 9.833 Self-insurance program for health care benefits. Retrieved
May 12, 2015, from http://codes.ohio.gov/orc/gp9.833
MacDonald, John. (2009). Health Plan Differences: Fully-Insured vs. Self-Insured. Retrieved June 16,
2015, from http://www.ebri.org/pdf/FFE114.11Feb09.Final.pdf
Self-Insured Health Plans. (2015). Retrieved May 26, 2015,
fromhttp://insurance.illinois.gov/HealthInsurance/SelfInsuredHealthPlans.asp
Wicks, E. K. (2002). Health insurance purchasing cooperatives. Commonwealth Fund. Retrieved from
http://www.commonwealthfund.org/usr_doc/wicks_coops.pdf.

79
Unions:
Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, Union membership rate in
private industry was 6.6 percent in 2014; public sector 35.7 percent on the Internet at
http://www.bls.gov/opub/ted/2015/union-membershiprate-in private-industry-and-public sector-in-
2014.htm (visited February 10, 2015).
Shannon M. Gibson and Joan B. Tucker Fife. (2014). What the ACA Means for Negotiating Employee
Welfare Benefits. Employment Relations Law Journal, Vol. 40 no. 1

80
Appendix E: Decision Making Tool
After your organization has requested health benefit proposals, the sample tables in this Appendix can help your organization organize and
compare various health benefit proposals. Part A can be used to determine if the health benefit proposals your organization requested
meet your organization's minimum specifications. Part B contains tables for evaluation of medical/prescription, dental, and vision plans. If
your organization is not evaluating vision plans, for example, do not complete that specific table. The tables contain sections for three
health benefit proposals, but additional proposals may be considered.
Part A: Minimum Specifications Evaluations
Overview: This table can be used to help your organization assess whether health insurance proposals meet the minimum
acceptable requirements for your organization. Extra rows are provided to enable you to add criteria specific to your
organization.
Step 1: In the column labeled, "Minimum Specifications," list the minimum acceptable benefits your organization will accept for
each listed criterion.
Step 2: Enter the dollar amounts for each proposal. Then evaluate whether each proposal meets the minimum specifications for
each criterion. Place a checkmark in the appropriate "Yes" or "No" column.
Step 3: Determine whether each health benefits proposal has met the minimum specifications. The costs of plans that have met
the minimum specifications can be evaluated using the tables in Part B.

81
Criteria Proposal 1 Proposal 2 Proposal 3
Minimum
Specifications
Dollar Amount Yes No Dollar Amount Yes No Dollar Amount Yes No
Co-payment for office visit
Co-payment for specialist
Co-payment for emergency room visit
Co-payment for urgent care visit
Deductible paid by the employee: Network,
Single Plan
Two Person Plan
Family Plan
Deductible paid by the employee: Non-
network, Single Plan
network, Two Person Plan
network, Family Plan
Network co-insurance percent that the plan
covers
Non-network co-insurance percent that the
plan covers

82
Criteria Proposal 1 Proposal 2 Proposal 3
Minimum
Specifications
Dollar Amount Yes No Dollar Amount Yes No Dollar Amount Yes No
Out-of-pocket maximum including the
deductible: Network, Single Plan
deductible: Network, Two Person Plan
deductible: Network, Family Plan
deductible: Non-network, Single Plan
deductible: Non-network, Two Person
Plan
deductible: Non-network, Family Plan
Are all the minimum specifications met? (Check "Yes" or "No.")

83
Part B: Evaluation of Costs for Health Insurance Proposals
Medical and Prescription Plans
Overview: This table can be used to help your organization assess the costs of medical plans and prescription plans of health
benefit proposals that meet the minimum specifications specified by your organization in Part A.
Step 1: In the column labeled, "Number of Employees," list the number of employees currently enrolled in that specific type of
plan.
Step 2: Complete the "Yearly Cost" column for each health benefit proposal. Plans may have the prescription plan included in the
medical plan. However, other plans may have the medical plan and prescription plan separate, in which case you need to add
the medical plan and prescription plan cost together and then list the cost in "Yearly Cost."
Step 3: Calculate the "Total Yearly Cost" column for each proposal by multiplying the "Number of Employees" column by the
"Yearly Cost" column for each row.
Step 4: Sum the "Total Yearly Cost" column for "Employee Total Yearly Cost" and "Employer Total Yearly Cost" to calculate the
total yearly cost for employees and employers for each proposal. This will provide you with a total cost figure for employees and
employer, respectively. These figures can be added together to provide a total cost.

84
Medical and Prescription Plan Costs Proposal 1 Proposal 2 Proposal 3
Number of
Employees
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Employee yearly premium
contributions: Single Plan
contributions: Two Person Plan
contributions: Family Plan
Employee Total Yearly Cost
Medical and Prescription Plan Costs Proposal 1 Proposal 2 Proposal 3
Number of
Employees
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Employer yearly premium
Employer Total Yearly Cost

85
Dental Plans
Overview: This table can be used to help your organization assess the costs of dental plans of health benefit proposals that
meet the minimum specifications specified by your organization in Part A.
plan.
Step 2: Complete the "Yearly Cost" column for each health benefit proposal.
Step 3: Calculate the "Total Yearly" column for each health benefit proposal by multiplying the "Number of Employees" column
by the "Yearly Cost" column for each row.
Step 4: Sum the "Total Yearly Cost" column for "Employee Total Yearly Cost" and "Employer Total Yearly Cost" to calculate the
total yearly cost for employees and employers for each proposal. This will provide you with a total cost figure for employees
and employer, respectively. These figures can be added together to provide a total cost.

86
Dental Plan Costs Proposal 1 Proposal 2 Proposal 3
Number of
Employees
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Dental Plan Costs Proposal 1 Proposal 2 Proposal 3
Number of
Employees
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost

87
Vision Plans
Overview: This table can be used to help your organization assess the costs of vision plans of health benefit proposals that meet
the minimum specifications identified by your organization in Part A.
plan.
Step 2: Complete the "Yearly Cost" column for each health benefit proposal.
Step 3: Calculate the "Total Yearly" column for each health benefit proposal by multiplying the "Number of Employees" column
by the "Yearly Cost" column for each row.
Step 4: Step 4: Sum the "Total Yearly Cost" column for "Employee Total Yearly Cost" and "Employer Total Yearly Cost" to
calculate the total yearly cost for employees and employers for each proposal. This will provide you with a total cost figure for
employees and employer, respectively. These figures can be added together to provide a total cost.

88
Vision Plan Costs Proposal 1 Proposal 2 Proposal 3
Number of
Employees
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Yearly Cost
Total Yearly
Cost
Vision Plan Costs Proposal 1 Proposal 2 Proposal 3

89
Part C: Additional Considerations
Overview: This table can be used to record additional general considerations and consortium considerations (as/if applicable) that your
organization may want to assess when considering health benefit proposals.
General Considerations Proposal 1 Proposal 2 Proposal 3
Fully-insured or self-insured health
plan?
Type of approval needed to switch
health insurance plans (e.g.,
renegotiation of contract, union
approval)?
Length of agreement?
Employees able to use the same
doctors and hospitals?
Any special programs offered (e.g.,
wellness program, disease state
management program)

90
Other General Considerations Proposal 1 Proposal 2 Proposal 3

91
Consortium Considerations Proposal 1 Proposal 2 Proposal 3
Annual fees for participating in the
consortium?
Number of health plans offered?
Number of members in the
consortium?
Number of members joining in last
two years?
Number of members leaving in the
last two years?
Number of lives covered?
Location of the consortium?
Pooled or allocated balance used?
Level of cash reserves?
Length of notice to leave the
consortium?
Claims history provided in a
regular/timely fashion?
Who pays run out?
Able to bring current plan to the
consortium?

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Other Consortium Considerations Proposal 1 Proposal 2 Proposal 3

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