Selling
Georgia ABF Advantages
Predictability and Savings, all in one health plan
Anthem Balanced Funding (ABF), a level-funding arrangement, is a solution that combines the predictable payment experience similar to that of Fully Insured, while allowing employers the opportunity to enjoy many of the benefits of traditional Self-Funding.
ABF Advantages at-a-glance
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Fixed monthly payments to keep the employer’s budget on target.
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Potential end of year savings More than half of Anthem groups receive a surplus.
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No deficit carry-forward protects employers if their group has high claims. They will not have to pay money back at the start of the new contract yet.
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Prefunded claims run-out helps employers avoid unexpected costs if they terminate the plan at the end of their contract year.
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Comprehensive monthly reporting gives you and your client full transparency into claims utilization, so you always know during the year if they are on track to receive a credit. Please see the Reporting section for more.
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Fast settlement Calculated within 90 days of the close of the contract year.
We’ve provided information you can share with your clients that explains the benefits of ABF in the marketing resources section.
Learn more
How it works
Four simple steps to saving and control:
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Employers pay a fixed monthly payment that includes:
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Administrative fees.
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Stop loss coverage.
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A paid-claims fund.
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Coverage for claims run out (also known as terminal liability).
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Employees use their benefits just as they would any traditional plan.
ABF is invisible to employees. See the employee experience section for more.
- Claims are reconciled at the end of the plan year, and the settlement information is delivered in 90 days.
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If a credit is due, it is applied to your client’s account on their next billing cycle after the settlement.
If there is a deficit, no payment is required. It’s covered and they don’t owe any additional money.
We calculate the ABF settlement within 90 days. Ask other carriers if they do the same.
A surplus can offer significant savings when you have a favorable claims year.
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Favorable claims year example
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Annual claims funding
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$240,000 |
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Paid claims
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$180,000 |
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Favorable balance
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$60,000 |
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If the surplus sharing percentage is 50%, Anthem will credit the employer $30,000. Group must renew with Anthem to receive credit.
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Unfavorable claims year example
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Annual claims funding
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$240,000 |
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Paid claims
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$320,000 |
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Negative balance
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-$80,000 |
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Anthem will cover the $80,000 deficit. Please note that any claims over the stop loss limits are excluded from the surplus calculation.
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Employee experience
Reimagining health plans to provide whole-person care
We’re driving innovations to help people better understand their health and to provide meaningful, empathetic solutions that connect them to care in simpler, more effective, and more affordable ways. This is especially important with ABF, since healthier employees will result in lower claims costs, and potential savings, for the employer. ABF is invisible to employees; they have access to the same benefits and networks as millions of other Anthem members.
Affordable, accessible, high value care
Our Blue Connection exclusive provider organization (EPO) health plans have a specially chosen network, the Blue High Performance Network (BlueHPN). Blue Connection EPO plans are available on the BlueHPN to both large and small groups.
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Curated to increase employees’ access to care
These high-performance providers are:
- Hand-picked in local markets based on performance.
- Accountable for outcomes, efficiency, and affordability.
- Responsible for coordinating core across the healthcare delivery system.
- Supported by enhanced analytics and insights, core delivery support, and streamlined administrative requirements.
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Coverage across the country and around the world
Nationwide, more than 1.7 million doctors and hospitals contract with Blue Cross Blue Shield companies - more than any other insurer. With the Blue Cross Blue Shield Global® Core program, members have access to hospitals and doctors around the globe.
Programs and resources to help employees stay on top of their health
Anthem’s ABF plans aren’t just about covering employees when they don’t feel well. Responsive and empathetic, our care programs enable real-time connections to prevent and intervene — driving stronger engagement and bridging gaps in care. Visit anthem.com for information on these wellness programs, available on all plans offered.
ABF plans include these health and wellness programs at no additional cost:
Sydney Health: The front door to care
The Sydney℠ Health mobile app provides one integrated care experience for better whole health. With Sydney Health, employees have a single point of access to their benefits, tools, and resources, including:
- Integrated benefit experience.
- Virtual Primary Care: check symptoms and engage in a virtual chat visit with a doctor, connect via video for urgent care, and schedule annual wellness exams.
- Health history via My Health Records.
- Easy pharmacy refills and updates.
- Access community resources.
24/7 NurseLine
24/7 NurseLine offers employees round-the-clock access to registered nurses. When employees have a health question or concern in the middle of the night or on the weekend, Anthem has registered nurses on the phone ready to answer health questions. From tips on allergy relief to choosing between the emergency room and urgent care, nurses are ready to guide people to the best treatment option.
Autism Spectrum Disorder Program
Autism Spectrum Disorder Program with Applied Behavior Analysis provides specialized family support and community resources, helping to guide employees through the complex healthcare system and make the most of their benefits.
Behavioral health programs
Behavioral health programs connect your employees to support resources when they need them — to help improve outcomes, increase value, and more effectively and affordably care for employees at every stage of health. Solutions include programs to help people reduce anxiety or depression, treat substance use, find caregivers, cope with eating disorders, and connect to social programs.
Care Optimization
Care Optimization empowers both at-risk employees and their providers with actionable insights by identifying and enabling them to take action on a variety of employee care- and cost-optimization opportunities.
ConditionCare Support
ConditionCare Support is available for employees with diabetes, asthma, heart failure, coronary artery disease, or chronic obstructive pulmonary disease (COPD). A team of experts will help employees manage their condition to enhance their quality of life and reach their health goals. Nurses, dietitians, and other health professionals are available anytime, day or night, to answer questions and help with care needs.
Building Healthy Families
Building Healthy Families is an end-to-end digital solution that goes beyond traditional maternity support to offer helpful resources from preconception through early parenthood. Key benefits include tools and trackers, high touch member interactions, and access to a digital library of resources. Experiences are personalized for each member and designed to connect them to useful resources to navigate every state of their unique journey.
Medical and behavioral health case management
After a hospitalization or serious or sudden illness, we provide nursing support by telephone to help your employees make the most of their medical benefits. Case management teams will arrange post-discharge care and services related to community health, cancer, neonatal intensive-care unit (NICU), or transplant needs.
MyHealth Advantage
MyHealth Advantage is a proactive outreach program designed to improve safety, quality, and care coordination through personalized messaging about opportunities to:
- Take specific actions to improve health outcomes.
- Optimize healthcare spending.
- Avoid drug interactions or other critical health issues.
Anthem is committed to providing people with guidance and support so they can make decisions with the confidence of care at all stages of their personal health journey. That means we deliver employer solutions that enhance care, while reducing cost and administrative burden.
Quoting
Underwriting and contract details
Know before you request a quote
As you consider which clients are the best fit for Anthem Balanced Funding, here are the underwriting and contractual details:
Individual Stop Loss:*
SG: $25,0000
Key: $35,0000
LG: $50,000
Aggregate Stop Loss:
SG: 120%
Key: 110%
LG: 110%
Minimum group size: 20 employees
Maximum group size: No maximum group size
Surplus Share: 50%
Participation requirement:
- 75% excluding valid waivers (all group sizes)
- LG also requires 50% of total eligible employees
Employer contribution requirement: 50% of employee-only premium
Ineligible SIC Codes: None
Maximum number of plans: 20+ enrolled, 3 plans
Commissions: Can be customized
*Other options may be available; contact your Sales rep for details.
Please note
- First-year contract basis is 12/12 with a 15-month run-out period for terminating clients. In subsequent years, the contract is administered on a paid basis.
- Anthem will not coexist with another medical carrier.
- Vision, dental, and supplemental products can be sold with ABF.
- Life and disability (sold through The Standard) can be sold with ABF.
- First-time groups who have never had previous medical coverage are eligible for ABF.
- Anthem may require Individual Medical Questionnaires (IMQs) in some circumstances. We will accept other carrier’s IMQs.
- Patient-Centered Outcomes Research Institute (PCORI) fees are the responsibility of the employer.
- Minimum Essential Coverage (MEC) filings: Anthem prepares the forms; employer is responsible for filing.
These provisions vary from carrier to carrier, so it’s important you and your client understand how ABF is administered.
Quoting
How to request an ABF quote
The following information is needed to ensure the most competitive quotes for ABF.
- Current and renewal rates, including rate component breakouts for groups that are currently self-funded, such as admin, rebate credits, individual stop loss premium, aggregate stop loss premium, or claim factors. If renewal rates are unavailable, Anthem will consider a conditional quote with renewal.
- Plan designs for all current and renewal plans; summary plan documents are preferable to summary of benefits and coverage.
- Census information, including first and last name, full address with ZIP codes, gender, date of birth, coverage tier, plan selection, and distinguishing label for employees and dependents.
- Claims experience for the most recent 12- to 24-month period including both claims and enrollment by month for groups that have it available. (For SG, it is highly recommended to obtain either an Anthem Multiple Employer Welfare Arrangement (MEWA) or an Affordable Care Act (ACA) quote before submitting an Anthem Balanced Fund (ABF) quote if the group can’t provide claims experience.)
- Large claim information including dollar amount and diagnosis for the same period as the claims experience for groups that have it available.
- Current employer contribution rates and contribution strategy, such as 50% of employee‑only rate.
Additional information that would also be appropriate for an ABF quote:
- Competitor quotes already received.
- Any in-force specialty lines of coverage that could be considered with the ABF quote.
- Any economic factors impacting the group’s current and/or future enrollment trends.
Comparing rates
Understand and accurately compare Anthem rates to competitors'
ABF groups pay the same amount every month. These fixed monthly rates are made up of five components:
Fixed costs
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Administrative Services Only fee to cover administrative costs and selling expenses. This includes standard broker commissions and pharmacy rebate credits.
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Specific (or individual) stop loss coverage that protects against large claims from individuals. Be sure any quotes you’re comparing are using the same attachment points.
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Aggregate stop loss coverage that protects against a high volume of overall claims.
Variable costs
If claims are lower, your client may get money back. If claims are higher, no additional payments are required.
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Paid claims fund that covers all claims for which the group will be responsible.
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Terminal liability provides funding to pay claims that are incurred during the plan year, but paid after the client terminates. If the group has a surplus and leaves Anthem, the group forfeits the surplus. If the group has a surplus and terminates its ABF contract but stays with Anthem, they will be eligible to receive a credit.
Anthem’s approach allows for predictable costs and credits
Ask other carriers how they fund terminal liability. Is it incorporated as a monthly component for the full plan year or charged at the end.
Details matter
With Anthem, the terminal liability is charged from the beginning. Why does this matter?
- Anthem provides consistent, stable pricing with no surprises.
- With a competitor, employers may think they are on track for a surplus and credit, only to learn the terminal liability fund has not yet been accounted for.
- Anthem’s ABF reports provide continuous details and insight into claims. You’ll know if the group is on track to receive a surplus. You can have confidence knowing there won’t be any additional charges or surprises in the final months of the contract year.
Post-sale
Enrollment and billing
All the information needed for a smooth setup.
In a typical ABF sale, there are basic documents that need to be collected in order to install the group in our system. This is what you can expect.
For Large Groups:
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Complete Employer Application Additional forms are included in the application. These include:
- HIPAA Notice
- HIPAA Identification of Designated Representative
- Group Health Plan BAA
- PHI Report
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Census Enrollment file Unique for each sold group
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Signed proposal Medical and specialty
For Small Groups:
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Easy online completion When we issue a quote we will include a docusign link in the email to send to your client for easy online completion. You can find training videos to guide you on SG online quoting and enrolling on Producer Toolbox by going to the “Support” section, selecting “Product and Training Updates” and “Georgia” when prompted. Please note the first bank draft could be for the first two months of coverage because this typically happens since Anthem bills one month in advance.
Important details
- EFT is required.
- Once installed, an email will be sent to the group administrator granting access to the billing and claims system.
- When specialty (dental, vision) products are sold alongside ABF, additional forms may be required. Your Anthem Sales Representative can walk you through this.
Billing
ABF groups are billed monthly, one month in advance. The invoice will include:
The detailed bill can be accessed from the EmployerAccess billing tab.
You can find common answers to billing questions your clients might have in the Anthem ASO Billing FAQ.
Learn more
Ongoing plan management
Encourage your clients to register for EmployerAccess, Anthem’s digital administration tool, as it is the only place your client will be able to view their bills. EmployerAccess is available online and as a mobile app. It is a customized administrative site for everything needed to manage and maximize an organization’s Anthem plans.
EmployerAccess gives your clients:
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A secure digital platform to enroll employees, make changes to enrollment, and view or pay an Anthem bill.
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An interactive, personalized dashboard to quickly navigate to tasks, the latest news, or transaction history.
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Support tools including live chat, frequently asked questions, and a self-guided tour to help first-time users.
Registering with EmployerAccess:
- Register or sign in at employer.anthem.com/eea.
- Bookmark the link for future use.
- Download the EmployerAccess app for benefits management, new, and alerts on the go.
Register or sign in
Including all of the needed forms and paperwork will result in a smooth, fast installation for your client. Ongoing management of the plan is easier using digital tools like EmployerAccess.
Tips for success
- The census tool can be found on the Producer Toolbox and is easy to fill out with the group’s information. Be sure to keep the form in its current format and fields for the quickest implementation of your client.
- If vision, dental, life, disability, or indemnity plans are also sold, please send the entire quote, not just the signed pages, to ensure the fastest process for your client.
Reporting
Understand what's driving costs and if your client is on track for a refund
Anthem Balanced Funding provides insights into what’s driving your client’s claims. Your client’s claims and financial information is packaged in an easy-to-follow report that includes key takeaways and action items to help drive costs lower. The Anthem Balanced Funding Review (ABFR) is a full reporting package and your one-stop source to see, quickly and easily:
- If your client is on track for a refund.
- What is driving claims utilization.
- Benchmarks to compare your client to similar groups.
You can learn more on the ABF Reporting Capabilities flyer.
View
Settlement
Important details about the year-end process
At year end, a settlement is calculated to reconcile money paid compared to the group’s claims liability fund. Settlements are generated automatically, 90 days following the end of the policy period. If a group renews, a surplus may be shared:
- Group receives 50% of the surplus.
- The surplus is returned to the group as a credit on their monthly billing statement.
- If the actual paid claims exceed the paid claims fund, there is a deficit. Deficits are forgiven. The group has no additional liability.
Contract settlement administration
For terminating accounts:
- There is a 15-month run-out period.
- Terminal settlement is completed within 90 days following the 15-month run-out period.
- 15-month run-out period excludes stop loss coverage.
- The final settlement will include both claims paid in the last policy period and run-out claims as compared to the claims fund from the last policy period, plus the terminal fund.
- No surplus will be returned to groups selecting another medical carrier. However, if the group terminates its ABF plan but keeps the medical coverage with Anthem, a surplus, if any, will be credited.
- Group has no liability upon termination with Anthem. If run-out claims exceed Terminal Liability Fund, Anthem takes on the liability — Anthem does not require groups to pay anything additional.
- During this time, no invoices or reports are sent to the customer.
Year-end settlement examples
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Favorable claims year example
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Annual claims funding
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$240,000 |
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Paid claims
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$180,000 |
|
Favorable balance
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$60,000 |
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If the surplus sharing percentage is 50%, Anthem will credit the employer $30,000. Group must renew with Anthem to receive credit.
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Unfavorable claims year example
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|
Annual claims funding
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$240,000 |
|
Paid claims
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$320,000 |
|
Negative balance
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-$80,000 |
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Anthem will cover the $80,000 deficit. Please note that any claims over the stop loss limits are excluded from the surplus calculation. The group is not responsible for the negative balance.
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Offer a health plan with end-of-year savings potential
Your clients deserve to feel covered, protected, and confident in their care. We’re your trusted partner to help you build an Anthem Balanced Funding plan that makes sense for them. Contact your Anthem Sales representative about Anthem Balanced Funding.