Presented by: Allen Koski, CEBS 302-797-3300 allen.koski@cigna

1. Global Wellness in the Healthcare Reform Era:Is The World Curved or Flat?ISCEBS NYC 14 September 2011 Presented by: Allen Koski, CEBS 302-797-3300 allen.koski@cigna.com

2. 4 Years Ago (2007) • Apple Introduces the iPhone • Price of Gold was $630/ounce • Final Harry Potter Book Released • World Stock Markets Plummet • Daimler sells Chrysler to an Equity Fund • Peru earthquake leads to Tsunami Warnings • Bulgaria and Romania join the European Union • Tiger Woods wins Thirteenth Major (will win only one more) • Time magazine in 2007 calling the Aztek one of the worst cars of all time

3. New Diseases since 1973 • 1973 Rotavirus: Infantile Diarrhea • 1977 Ebola: Hemorrhagic Fever • 1981 Staphylococcus aureus: Toxic Shock Syndrome • 1982 Borrelia burgdorferi: Lyme Disease • 1983 HIV: AIDS • 1989 Hepatitis C: Parentally Transmitted Liver Infection • 1993 Hantavirus: Adult Respiratory Distress Syndrome • 1995 Ehrlichiosis: Severe Arthritis • 1996 nvCJD: Creutzfeldt-Jacob Disease • 1997 H5N1: Influenza • 1999 Nipah: Severe Encephalitis • 2000s: Methicillin-resistant staph (MRSA) • 2009: H1N1 Flu Epidemic?

4. Network Development Global Health & Wellness Patient Advocacy BUILDING OUT [ ] [ ] WHAT WAS Evolution of the Global Health Care Management Model The Goal: High Quality Care Worldwide, integrated health care delivery system providing the highest quality of care available in any given locale and bringing together worldwide best practices. Member Beware Risk Protection Only Member

5. What Will Change 4 Years Hence: • Networks a mile wide and a few facilities deep: care in countries where no networks or pre-arranged payment systems exist and Medical CPI (200 Countries) • Widen the Circle of Care: Post treatment coordination and recuperative care • Managing dynamic change in global healthcare, IEAP, dental, and disability • Local insurance requirements to support VISA concerns and Healthcare Reform • Corporate Global Wellness Initiatives • Expatriate population continues to age and get more diverse • Great “Black Swan” event planning • Medical Tourism or Regional Options

6. Tri-State Depot and Global Inc.

7. International Benefits versus Domestic (US) Benefits • Medical, Dental, and Prescription Drug: Transactional • Life and AD&D: Commodity • Evacuation and Repatriation, EmployeeAssistance Program (EAP): Duty of Care Important • Long Term Disability (LTD): Hybrid Transactional and Commodity • Short Term Disability (STD): Salary Continuation

8. Plan Design Differences • International is Insured, Domestic is often Self-Insured • Location of Assignment and Dependent Location • Location where the Plan will be Monitored and Maintained • Specific Subgroup Requirements • Country Specific Minimum Requirements • State Minimum Creditable Coverage (MCC) • Out of Pocket limited to $5,000/10,000 in Massachusetts

9. Domestic Trends = Cost X Utilization International Trends = Cost X Locations X Fx X CPI X Movement of Members X Medical Advances X Utilization International plans tend to less expensive overall but have higher trend Domestic vs. International Cost Projections

10. Country Specific Variations: • Dubai: Need a local plan number • UK: A Surgeon in “Mister” • France: 3/5/09 is 5/3/09 • Japan: 96 hour maternity is the norm • China: No screened blood supply • Germany: Alternative Therapy • Singapore: Ritalin is a “Controlled Substance” • Global: Hardware versus Software • US: Cost, Access, Quality • UK: Employer benefits contributions are taxed to Employee

11. Global Traveler Checklist Visa Support Pre-Trip Healthcare Provider Listing ICE Strategy Security Procedures Travel Security WHO HR CDC Traveler Risk Mgt StateDept Medical News Contingency Plans

12. Health Care Challenges Multitudes of clinical protocols and dangers: • Post treatment coordination and recuperative care • Avoid counterfeit prescription medications • Dealing with local traditional non-medical treatments • Medical evacuation protocols, post treatment options • Unscreened blood supplies Difficult administrative issues • “Hardware” and “Software” match • Paying for emergency care in countries where no networks or pre-arranged payment systems exist • Local insurance requirements to support VISA concerns • Payment using any type of currency available

13. Global Network Medical Cost Savings Global Wellness Tools US Networks Total Medical Cost

14. Summary of Differences • Recognize that international assignment demands are more complex and require specialized attention • Medical capabilities are variable country to country • Global service partners must improve business performance • By delivering services that reduce the administrative burden of health care and associated costs • Protect the investment made in human capital and allow international assignees to focus on what matters most within their respective businesses • Do not forget everything is multiplied in complexity when someone is facing a new situation • Work within different cultural norms

15. Challenge Question: What Matters To You Most In a Program? • Designing a Globally Compliant Solution • Cost Effective, Comprehensive Coverage • Easy Member Experience • Unrivaled Global Network • Wellness Tools to Improve Health

16. Mod 2: Overview of the Impact of Health Care Reform on Global Employees • Many Governments around the world have changed their view about medical coverage (Locals and Expats). • UAE: Expats are now required to show proof of coverage before getting a work visa, • Czech Republic now requires Locals and Expats to get minimum coverage levels thru a non-government insurance company, • Russia requires a minimum level of medical coverage, with any insurance company, • Some national systems require all employers to pay into one system for both Locals and Expats.

17. Delivering Global Benefits is Complicated: Legal Middle East Saudi Arabia • Coverage has to be provided by a locally-admitted carrier • Minimum coverage requirements (CCHI) United Arab Emirates • Coverage has to be provided by a locally-admitted carrier • Plans must be filed with local authorities (HAAD) • Impact on obtaining a visa Australia • Illegal for any non-registered health fund to pay claims for Medicare eligible Australians • Having private health insurance with an AUS registered health fund allows Australia taxpayers to claim exemption from 1% Medicare Levy Surcharge, if eligible • Minimum benefits are required to allow for 457 Visa Letters to be issued for non-Australians working in Australia

18. No preexisting condition exclusions. Waiting period limited to 90 days. Must follow rating limitations. Guaranteed issue. Guaranteed renewability. No discrimination based on health status. No discrimination against health care providers acting within scope of their license. Must cover essential benefits. Must follow cost-sharing limits. Must cover clinical trials without additional conditions. US: Patient Protection and Affordable Care (PPACA) Act of 2010 New Plans New and Grandfathered Plans 2010 2011 2012 2013 2014 2015 2016 2017 2018 18

19. PPACA: Provisions Phased in until 2018 Implications • No discrimination in favor of highly compensated individuals. • Dependent age rises to 26 years • Minimum loss ratio requirements (80%/85%) • Broker commission in/out of the program? • Is the individual mandate legal or not? • 2018: Introduction to high value plans ($11,200/$27,500) • What waivers will be granted? What state requirements? • Will insurers withdraw from markets? • Will Americans be allowed on “offshore” plans after 2014? 2010 2011 2012 2013 2014 2015 2016 2017 2018 19

20. Global Plan Options: Post Healthcare Reform (PPACA) • It appears that domestically sitused expatriate plans will be subject to some of the new law provisions. • leave US citizens on a US PPACA compliant plan but cover the TCN/KLNs under a separate “offshore” policy, again assuming the US employer has a place of business in a location where a local policy can be legally issued; OR • create a sub-group under the US policy made up of only TCNs and KLNs with cover that differs from the PPACA compliant cover provided to the other group on the principles that (a) these groups could be grandfathered (if renewing), and (b) presumably the PPACA was not intended to require certain types of cover for non US citizens based outside the United States and thus a client is willing to assume the risk that it is unlikely that the government would pursue non-PPACA-compliant levels of cover for non-citizens residing outside the United States. • Don’t forget other issues like Massachusetts Credible Coverage Minimums

21. Asia: • Morale/Engagement & Productivity, Reducing Presenteeism Mod 3: Business Plan on Deploying International Wellness Programs Multi-national workforce means varied health and wellness concerns: • Europe: • Productivity, Reducing Presenteeism & Morale/Engagement • Canada: • Productivity, Reducing Presenteeism & Morale/Engagement • United States: • Reducing Health Care Costs & Productivity, Reducing Presenteeism • Africa: • Productivity, Reducing Presenteeism & Absence Management • Australia: • Productivity, Reducing Presenteeism & Absence Management • Latin America: • Productivity, Reducing Presenteeism & Maintaining Work Ability

22. A Different Way of Thinking Addressing health care demand and spending from both sides of the problem Annual Patient Cost $ Case Management Earliest interventions help prevent costly medical events Disease Management Disease Management Traditional medical management respondsto disease/illness Utilization Management Q4 Q-12 Q-10 Q-8 Q-6 Q-4 Q2 Q4 Q6 Q8 Q10 Q12 Q-2 Q0 Preventing/Slowing Responding/Reversing • Health Promotion & Wellness • Lifestyle Behavior Modification • Chronic Condition Support • Disease Management • Acute Care Coordination Original chart source: Musich,Schultz,Burton,Edington. DM&HO. 12(5):299-326, 2004

23. Condition Management • Chronic condition support & management: A comprehensive approach to managing the course and impact of chronic conditions • Look for active versus passive program • Proactive identification of high risk patients • Program with consistent service experience, regardless of patient location • Holistic patient management, not just managing events of treatment • “health, family, and life management” not just medical management • Outreach for the purpose of education and intervention, so as to change behavior and manage compliance

24. Condition Management: Diabetes Triage Logic DIABETES? Do You Take Insulin? Level 3 YES YES NO Do You Know Your Hemoglobin A1C Levels? Is it Above 7? Level 3 YES YES NO / Next NO NO Level 3 Level 3 Do You Take 2 or More Meds a Day for Diabetes? YES NO Level 1 if Low Risk country; Level 3 if High risk country

25. Health Programs: Virtual Second Opinions Access to internationally-recognized experts for confirmation of life-threatening/life-altering diagnoses and treatment recommendations, without requiring the expat to travel or incur out-of-pocket expenses. Look for: • Utilization of a specific world-class vendor (recognized expertise) • Intended for use for serious illness, complex cases • Provision of more treatment options beyond what’s available locally • Receive world-class opinions without the cost/disruption of traveling

26. Health Programs: International Employee Assistance Program Immediate access to confidential services for behavioral health assessment. Have three levels: Telephonic, Face-to-Face and Work/Life Support. Look for: • Service Level: 24/7 with multiple access points: telephonic, email, online chat or SMS Text. • Telephonic triage and crisis intervention services • Local language Face-to-Face Sessions • Work/Life Support: Child and Senior Care • Local language access (23 Regions) • Structure telephonic counseling (170 Countries)

27. Wellness Program: Health Assessment • Collects individuals’ health information by asking a series of questions: • Personalized health risk report to make changes to unhealthy lifestyle habits: • Behavior modification to instill healthy habits before condition appears • Self-directed, online programs available in many languages and culturally adapted • Targets four key areas of modifiable health risks: • Sleep Habits • Stress Management • Healthy Eating • Physical activity

28. Challenge Question: What Wellness Program Will Have the Greatest Inpact? • Health Risk Assessment for Expatriates • Health Risk Assessment for Locals • Condition Management Program • Virtual Second Opinion • International Employee Assistance Program

29. Business Plan • Prepare for “Black Swan” Events (ICE Strategy) • Gap Analysis between Healthcare Provider, Workers Compensation Provider, Evacuation Vendor • Harmonize Medical Evacuation and Security Evacuation • Review Legal Requirements at Local and Global Country Level • Have Global Dental and EAP Providers • More Local Options Before Evacuation • Screen Chronic Conditions Before Deployment • Have Regional Options in Place • Understand Healthcare Reform Initiatives by Country • Offer Wellness and Pre-Departure Tools • Consider Segmented Expatriate and Third Country National Plans • Recognize Corporate Duty of Care Requirements

30. “Sometimes I'm confused by what I think is really obvious. But what I think is really obvious obviously isn't obvious...” Michael Stipe, Lead Singer REM

31. Questions to Ask • Are global health plan higher or lower than domestic? • Are there any downsides to putting in a plan? • How is eligibility handled? • Can you do VISA letters to help with immigration requirements? • What reporting in offered? • Are there countries where the program does not work? • Should we purchase war risk or terrorism coverage? • Discuss employer contribution strategies for expats, TCNs and Key Locals? • How do you do implementation meetings? • How does healthcare reform(s) affect our global benefit levels? • How should we handle short term assignments? • How does HR and Risk Management manage multiple vendors? • Does the evacuation, healthcare or workers compensation vendor take the lead on medical emergencies? • What do you think about multinational pooling?

32. CIGNA International Expatriate Benefits – A Market Leader in Global Healthcare