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Hey Doc! Six ways
Critical LifeEvents®
supports the way
consumers experience
critical illlness today
Dr. Howard Fixler
Medical Director & Second Vice President, Long-term Care & Disability
Trustmark Voluntary Benefit Solutions
Dan Johnson
Vice President, Sales & Marketing
Trustmark Voluntary Benefit Solutions
Change leads to innovation
The questions…
plans
• Classic
Why do CI
plans need to change?
• Why are a third of all CI claims in the
industry getting denied?
• What are the primary claims submitted?
The answers…
•
•
•
CI plans aren’t keeping pace with medical
practices
66% of denials are due to conditions not
being covered or definition not being met
90% of all industry claims are for cancer,
heart attack and stroke (94% for
Trustmark)
Change leads to innovation
70% were interested in early identification coverage
and typical plans don’t cover it
E.g., mini-stroke, skin cancer & tumors
64% were interested in early stage illness coverage
Critical LifeEvents®
where preventive measures are taken
E.g., artery obstruction repair and stroke prevention
procedures
Less than 50% would actually purchase a rider
which covered those ‘Other Conditions’
Six ways Critical LifeEvents® supports an employee’s
medical experience
1. Reflects current clinical practices
2. Covers earlier stages of diseases
3. Covers more conditions
4. Simplifies the claims process
5. Expands clinical diagnosis
6. Eliminates separation and modifies reocurrence periods
1. Reflects current practices
Classic plans
Critical LifeEvents®
Heart attacks have to be
diagnosed through
enzymes in order to be
paid.
Heart attacks are no longer
diagnosed through
enzymes alone, which
expands the definition of
what’s paid through Critical
LIfeEvents.
1. Reflects current practices
Percutaneous Coronary Intervention
Heart attack
10 minutes
Catheterization lab
REFLECTS CURRENT PRACTICES
1. Reflects current practices
Classic plans
Critical LifeEvents®
Stroke benefits are only
paid if a 30-day neurologic
deficit is present.
Strokes aren’t causing as
many neurologic deficits
because of early diagnosis
and interventions, so a 30day deficit doesn’t
preclude the benefit.
1. Reflects current practices
Why are strokes causing fewer
30-day impairments?
•
•
•
•
Earlier diagnosis
More designated stroke
centers
Better diagnostics
Clot-busting intervention
©American Heart Association, Inc. All rights reserved.
1. Reflects current practices
$15,000 benefit
January 2016
March 2016
Critical LifeEvents®
Critical LifeEvents®
Clinical diagnosis of stroke – 50%
Stroke w/ 30-day impairment – 100%
$7,500 ✓
$7,500 ✓
Supportive neuroimaging
COVERS EARLIER STAGES OF DISEASES
2. Covers earlier stages of diseases
Classic plans
Critical LifeEvents®
Contracts are limited and
rarely cover the early
stages of a disease.
Provides a benefit for the
early identification and
early stages of cancer,
coronary artery disease
and cerebral vascular
disease.
2. Covers earlier stages of diseases
CANCER
Classic plans
Critical LifeEvents®
Melanoma in-situ
Melanoma in-situ
0%
HEART
ATTACK
STROKE
10%
Classic plans
Critical LifeEvents®
Clinical diagnosis of coronary
artery disease
Clinical diagnosis of coronary
artery disease
0%
10%
Classic plans
Critical LifeEvents®
Mini-stroke (TIA)
Mini-stroke (TIA)
0%
10%
3. Covers more conditions
Classic plans
Critical LifeEvents®
•
•
•
•
•
Limited to established cancer
Heart attack
Stroke
Claim definition of in-situ vs. medical
definition of in-situ
Covers cancer, heart attack & stroke more
comprehensively
–
–
–
•
•
•
Early identification: 10% (TIA, melanoma & in-situ)
Early stages: 50%
Late stages: 100%
Benign tumors (brain, spinal cord or cranial
nerve)
Myelodysplastic syndrome
Invasive basal cell skin cancer
4. Simplifies the claims process
Classic plans
Critical LifeEvents®
In-situ I Invasive
Stage 1 I Stage 2 I Stage 3 I Stage 4
Claims denied because the language is too
restrictive
Allows for high mortality cancers to be covered,
even if the cancer is localized (i.e., pancreas,
esophageal, liver, biliary tract, lung, head/neck,
leukemia, lymphoma, multiple myeloma)
Conventional plans use the claim definition of in-situ, whereas Critical LifeEvents uses the medical definition of in-situ.
4. Simplifies the claims process
Classic plans
Pancreatic cancer
25%
(potential)
Critical LifeEvents®
Pancreatic cancer
100%
Located at site of
origin; not affecting
neighboring tissue
©Mayo Foundation for Medical Education and Research. All rights reserved.
5. Expands clinical diagnosis
Clinical diagnosis:
A diagnosis by a physician
based on clinical evidence,
which includes
documentation of clinical
exam, clinical impression,
imaging studies or
diagnostic test results.
Clinical diagnosis must
include recommendations
for treatment.
Classic plans
Critical LifeEvents®
Focus on more rigid
criteria.
Expands clinical diagnosis
in all categories of illness
(cancer, heart attack,
stroke) to 50%
5. Expands clinical diagnosis
Classic plans
Critical LifeEvents®
Clinically diagnosed heart
attack
Clinically diagnosed heart attack
Classic plans
Critical LifeEvents®
Clinically diagnosed stroke
Clinically diagnosed stroke
Classic plans
Critical LifeEvents®
Mini-stroke (TIA)
Mini-stroke (TIA)
Classic plans
Critical LifeEvents®
Initial diagnosis coronary
artery disease
Initial diagnosis coronary
artery disease
50% ✓
50% ✓
10% ✓
10% ✓
6. Eliminates separation & modifies reoccurence periods
Classic plans
plans
• Classic
Requires
90 days for new covered condition
•
•
Requires 12 months for reoccurring
condition
In case of cancer progression, must be
treatment-free for at least 12 months.
Critical LifeEvents®
•
•
•
Requires no elimination period for a new
covered condition
In case of cancer progression, a 30-day
confirmation of ‘No Evidence of Disease’ is
needed
Replenishing annual benefit
Six ways Critical LifeEvents® supports an employee’s
medical experience
1. Reflects current practices
2. Covers earlier stages of diseases
3. Covers more conditions
4. Simplifies the claims process
5. Expands clinical diagnosis
6. Eliminates separation and modifies reocurrence periods
Dr. Howard Fixler
Medical Director & Second Vice President, Long-term Care & Disability
Trustmark Voluntary Benefit Solutions
[email protected]
Dan Johnson
Vice President, Sales & Marketing
Trustmark Voluntary Benefit Solutions
[email protected]