Benefit Administration Town Hall Information
Presentation Slides
Town Hall Video (YouTube)
Benefit Advisory Group
Town Hall FAQ
- I understand that the cost will not go up because of our contract for the next year.
What happens to the cost afterwards? How much will it go up?
The District has covered 27% in premium increases over the last several years, in
addition to an 8% increase for the 2026 plan year. The cost of insurance will likely
continue to rise due to matters beyond our control, such as market trends, inflation,
and large claims. However, the District will continue to do what it can to mitigate
the impact of these increases on employees while following collective bargaining agreements.
- Our dental plan has seen multiple providers drop Delta Dental; is that because it’s
self-insured, and will similar situations occur with health care providers dropping
us once we are self-insured?
No, that issue has nothing to do with being self-insured. Dentists add and drop insurance
providers depending on patient load, ease of use, reimbursement rates, and other factors.
- If I have met my out-of-pocket deductible for the year, will I still have met my deductible
once the change occurs? Will the deductible amounts change in any way?
Your out-of-pocket maximums, copays, and deductibles paid this calendar year will
be carried over when we change insurance programs. This change would happen effective
10/1/2025.
- Will our medication from Costco pharmacies still be free?
Yes, generic prescriptions will still be free at Costco pharmacies.
- What is the process for emergency care or more complex medical care outside of the
network? For example, if I have a blood clot that requires removal, but only USC or
UCLA is able to provide this specialized surgical procedure, do agreements or processes
exist to navigate this situation?
UCLA is covered by our current plan. In-network and out-of-network rules still apply
as they would with our current plan.
- I want to stay with my current medical provider and have no interest in being referred
to another provider and starting over. Will I be able to keep my current provider?
The District is staying with Anthem as our health insurance carrier. If your provider
currently takes your insurance, then your provider will still be able to take you
as a patient when we switch insurance programs.
- Will the Teledoc Health service be free?
Yes. Please note that deductibles, coinsurance, and copays may still apply.
- Is Teledoc Health available to everyone or are high-deductible plans excluded?
Yes, the Teledoc Health service remains available to everyone. Please note that deductibles,
coinsurance, and copays may still apply.
- Does this change anything for our workers comp coverage, benefits, or plan?
No, workers comp is managed through a separate Joint Powers Agreement (JPA).
- Will we still have the same American Fidelity for our FSA and DFSA plans, or will
this be done with our new TPA?
FSA & DFSA would stay with American Fidelity.
- Is our medical information private or will District staff be able to access and view
it?
Yes, your individual medical information is private. District staff will have no access
to individual medical information.
- I have heard that Midi is only for people in menopause. I would like to know how many
people are currently using it, if continuing to offer the service is cost effective,
or if a similar service is already included in the other benefits we receive?
Midi focuses on women’s health. We do not have utilization data on Midi and although
there may be other programs available that focus on women’s health, we intend to keep
Midi.
- If this new self-insured model under Pareto doesn't meet expectations, is there a
plan or timeline to re-evaluate or return to a pooled group like SISC?
The initial contract with Pareto and BRMS will be one year, however it will likely
require more time to determine if the transition was “successful”. But we can always
return to SISC or a similar JPA program if things do not work out as planned.
- During the Zoom Town Hall, Ruben spoke about managing our chronic conditions to see
what our cost will be. Does that mean that someone will be looking into our medical
records then to make this determination? If so, who will be doing that?
District staff will not be reviewing medical records. Chronic condition and wellness
management is an added benefit through BRMS and would be employee driven and can help
employee groups be healthier. District management will have access to overall utilization
data that can be used to offer more focused programs.
- The email also states “two years of research and discovery” were conducted. When did
this process take place that was intended to ensure transparency? Do notes or records
exist?
This has been an ongoing discussion in the benefit advisory group. HUB and Pareto
have presented to the group as well. All employee groups are represented on the benefit
advisory groups with the intent that they disseminate information as it is received.
- What changes in plan choices can we anticipate?
For now, none. Plan choices currently remain the same.
- What stop-loss/reinsurance policies are in place to protect against large claims?
There is a stop-loss/reinsurance policy in place through Pareto via Sunlife Financial.
- Will our future cost/premiums be decided by our own use of the insurance? This could
be worrisome to those who have a chronic condition needing durable medical equipment
(DME). Is it possible that DME needs will not be covered in the future?
No, it’s not individually rated. AHC is still rated as a whole group and durable medical
will continue.
- Is there a grievance/appeals process?
A grievance is a response to a collective bargaining contract violation, so unless
a contract violation occurs, the grievance process doesn’t apply. BRMS and Anthem
do have an appeals process for claims if needed.
- Since we will continue to have Anthem Blue Cross, does that mean that we will have
continuity of care? That is, will we be able to continue seeing our current doctors?
Will we have new ID numbers that we will have to update with our doctors?
You will receive a new ID card with an updated ID number that will need to be provided
to your doctor(s).
- What other value-added products can be added in the future to our current plans to
support member health? (e.g. discounted gym memberships, support for employees needing
GLP-1 medication, etc.)
By being self-insured, we hope to be able to add additional value-added products for
our members use. Currently, SISC does not provide the District with utilization data
of value-added programs. Moving forward, the goal is to utilize data to update our
value-added programs to better suit the District’s needs.
- What is the difference between Pareto, BRMS, and HUB?
Pareto is an employer collective, which is a group of employers sharing the claims
risk and managing the stop loss insurance. BRMS is the third-party benefit administrator
responsible for the day-to-day administration of our medical benefits. HUB is our
local insurance broker.
- Who has been on the health benefits negotiation team and how long has the team been
active?
There is no health benefits negotiation team; changing benefit administrators does
not require negotiations. This transition has been facilitated by a Benefit Advisory
Group alongside a small group of District management.
- Has a contract already been signed and can we go back to SISC?
At the time of the town hall, a contract had not been signed. Yes, we would likely
be able to go back to SISC or another similar JPA or program if the new program does
not work out as planned.
- What safeguards are in place to ensure that any future shortfalls in funding are not
passed onto employees in the form of higher premiums or reduced benefits?
The District has covered 27% in premium increases over the last several years, with
an 8% increase for the 2026 plan year. The cost of insurance will likely continue
to rise due to matters beyond our control, such as market trends, inflation, and large
claims. However, the District will continue to do what it can to mitigate the impact
of these increases on employees along with following collective bargaining agreements.
- Will we be able to continue seeing our past medical history?
Yes, your medical history will live with your physicians and with Anthem.
- If AHC will be self-insured will the risk management be fully AHC? Has the district
considered possible future budget falls? I'm thinking the health of our state budget
and how in the coming years it will affect the AHC budget.
We will be part of a risk pool with Pareto Health and be backed by additional stop-loss
insurance for large claims. We will also receive our initial investment with SISC
back, which will be held in a health benefit reserve fund.
- Who should we contact for questions about our benefits?
As the Benefits Coordinator, Pam Blanchard is always available for questions.
- Since self-insured health groups are not subject to California regulation by the CA
Department of Insurance, who will regulate it?
Self-funded health insurance groups in California are primarily regulated by the Employee
Retirement Income Security Act (ERISA). While the California Department of Insurance
(CDI) and Department of Managed Health Care (DMHC) regulate fully-insured health plans,
self-insured plans are largely exempt from state insurance laws. The U.S. Department
of Labor, through its Employee Benefits Security Administration (EBSA) enforces ERISA.
- During the Town Hall, there was a slide talking about "Risk Shield", "no new lasers"
and "caps stop-loss increases". What do all these terms mean?
The “risk shield” is the protection we get from Pareto and the stop-loss contracts
they provide. We have a guaranteed rate cap on all our stop-loss renewals. A laser
is the identification of a certain high cost member which a stop-loss carrier can
make an employer pay more claims for. The “no new laser” provision prohibits the stop-loss
carrier from ever implementing a higher charge on a specific employee due to higher
claims. The District is going into Pareto with no “lasers” and will never receive
a new laser going forward due to being a part of Pareto.
- Will benefits enrollment still occur in July? And the change will take effect in October?
When will we have access to detailed information on the new health insurance, so we
may make our best informed decisions about our total benefit choices and costs?
Yes, the open enrollment will still be in July and the change will take effect in
October.
- Are there other legal requirements to going self-insured that will bring additional
cost to the District that will be passed on to faculty and staff?
No. We are already self-insured through SISC, so nothing changes by moving to Pareto
and BRMS from a legal perspective.
- I know sometimes it takes a while for insurance to pay the doctor for a visit. Do
you anticipate any issues during the change-over if one of our visits has yet to be
billed or paid?
Your out-of-pocket maximums, copays, and deductibles paid this calendar year will
be carried over when we change insurance programs. This change will happen effective
10/1/2025.
- Are there any local organizations or colleges that are currently utilizing BRMS and
HUB?
Yes, there are local organizations who self-insure with Pareto, BRMS, and HUB. They
are all large, well respected organizations. We have reached out to some of the local
companies who self-insure with these groups, and they have provided encouraging feedback.
- It used to just be SISC, and now it's three separate groups... Will the partnership
with Pareto, BRMS, and HUB complicate things, such as claims review, payments to doctors,
etc.?
No. BRMS will be the main claims administrator and HUB will work with the District
as our broker. All three entities have entirely different roles and will have little
to no impact to employees.
