Employment Resources

If you haven’t considered the “graying” of the current workforce, perhaps you haven’t reviewed current Department of Labor statistics:

• The median age of all U.S. employees is 40.4 years.
• The median age of employees in public administration is 43.8 years.
• The median age is 43.5 years in education and 43.0 years at transportation and utility companies.

Compare this data with a statistic provided by UnumProvident, a Tennessee-based group health insurance underwriter. They found that an increase of just one year in the median age of employees could increase claim costs anywhere from 4% to 8%. This is just a sampling of the findings that resulted from their recent study entitled “The Health and Productivity in the Aging American Work Force: Realities and Opportunities.” The population for the study came from UnumProvident’s disability database. Their research included 26.8 million covered individuals and approximately 178,000 employer policyholders.

Although the study revealed that workers age 40 and older display a lower incidence of work injuries, short-term disability, and unscheduled absences than their younger colleagues do, the average amount of time older workers miss because of an injury or illness is almost a third more. The study went on to note that the middle-aged workers account for 50% of all short-term disability claims, and almost 75% of long-term disability claims.

The main reasons for long-term absences for this employee demographic include problems with the musculoskeletal and circulatory systems in addition to mental diseases and cancer. Risk factors such as smoking, lack of exercise, and obesity can lead to healthcare costs for the middle-aged workers that are nearly 300% higher than for younger employees.

The challenge for employers with a significant middle-aged population is to find a methodology to keep their experienced workers, but not subject themselves to the high cost of disability claims in doing so. The answer to the problem lies in establishing wellness programs that meet the health needs of your aging workforce.

The University of Washington Health Promotion Research Center offers the following suggestions for creating an aging workforce wellness program:

Adopt and Implement Policies and Programs Proven to Work.

• Provide smoking cessation counseling and medications.
• Provide breast, cervical, and colorectal cancer screening, and blood pressure and cholesterol risk detection and management.
• Institute physical activity and healthy eating promotion, with emphasis on weight control.
• Facilitate smoking bans and stair-use reminders.

Align Employee Incentives toward Receiving Services and Participating in Programs.

Reduce or eliminate cost-sharing — Reducing out-of-pocket costs has been proven to increase use of breast cancer screening and tobacco cessation treatment. Reducing or eliminating these costs for other known high-value services, such as screens for blood pressure, cervical cancer, cholesterol, and colorectal cancer could increase their use as well.

Provide Easy Access and Use — Reducing structural barriers such as location, hours of operation, and availability of childcare has been shown to increase participation in breast and colorectal cancer screening. Creating or improving access to places for physical activity, including walking, also increases the potential for employees to participate.

Communicate “Why” and “How” Information and Track Results

Offer compelling insight, rationales, and guidance for using health promotion services and activities — Motivating employee participation requires communicating about why and how to use the policies and programs being offered. Specifically, Health insurance benefits that include no-cost screening and smoking cessation are more likely to be used if they are promoted using standard marketing and communication principles.

Assess employee needs — Surveys, such as Health Risk Assessments (HRA), can generate information on employee health status and health risks that helps employers make smart, targeted health promotion investments. Survey data, which should be anonymous to the employer, will also establish benchmarks against which employers can assess the effectiveness of their investments over time.

Any benefits or human resources professional who has been through an open enrollment season knows the importance of communication in ensuring that the enrollment process goes smoothly and successfully. Yet, overall, employers still have work to do in crafting and delivering communications that engage employees and result in their careful and considered selection of benefits.

A survey from the Guardian Life Insurance Company found that almost half of employees spend little or no time reviewing their benefits options each year. On average, the survey found, employees spend 1.4 hours reviewing benefits selections, compared with the 2.8 hours they spend preparing and filing taxes and the 4.9 hours they spend on holiday shopping. The result, according to the survey, is a basic misunderstanding about the advantages of group benefits products. For example, though 70% of surveyed employees said they knew the differences between Group and Individual Life insurance coverage, almost half of these employees said they thought a medical exam was required to enroll in Group Life insurance. And, though two-thirds of employees said they knew the differences between Group and Individual Disability coverage, almost half believed they needed a medical exam to enroll in the group plan. For both of these coverages, medical underwriting is not typically required. Furthermore, nearly a quarter of the employee-respondents thought that Group Disability coverage would be more expensive than an individual disability product.

Employers recognize these communications challenges. A survey from human resources consultant Watson Wyatt found that communications challenges topped the list of employer concerns during the most recent annual benefits enrollment period, with 63% of surveyed firms citing employee communication as a top challenge. More than a third (36%) cited more fully engaging employees in the enrollment process as a top challenge. In contrast, the surveyed employers were highly satisfied with the transactional aspects of benefits enrollment, with 75% being satisfied or very satisfied with the completeness and accuracy of the selections made (the average company reported that two-thirds of employee enrollments were completed on the Web).

Many of the employers reported employee concerns with those parts of the enrollment process that require employees’ thoughtful decision making — contributions to Health Spending Accounts, choosing between different plans, coordinating with a spouse’s plan. Also, 28% cited the complexity of the enrollment process as an employee concern, while 27% cited employee challenges grappling with plan changes.

The past several years have seen the continued shift of responsibility to workers for an increasing number of decisions involving employee benefits. Clearly, this shift heightens the need for communications that not only inform employees, but also engage them as involved, educated decision makers. Now is a good time to critically review your last open enrollment period, talk with employees about their experiences, and assess both the successes and failures of the process. The information that you glean can be invaluable as you craft communications for the next enrollment period.

For 2008, the contribution limit for an individual with self-only coverage under a qualifying high deductible health plan is $2,900. For an individual with family coverage, the limit is $5,800.

A qualifying high deductible health plan, for 2008, is defined as a health plan with an annual deductible greater than or equal to $1,100 for self-only coverage, or $2,200 for family coverage (unchanged from 2007). The limit on annual out-of-pocket expenses is $5,600 for self-only coverage, or $11,200 for family coverage.

The current limits and corresponding 2007 limits for self-only and family coverages are compared in the chart below.

Business considerations, and perhaps personal ones, guide an owner’s decision to sell a company or to expand operations through a merger or acquisition. Consequently, issues involving employee benefits plans are sometimes overlooked until well after the deal negotiations are underway. Delays in recognizing the importance of employee benefits issues to a merger or acquisition can increase the complexities of the transaction and/or create obstacles to its completion.

Benefits plan-related issues can impact merger/acquisition negotiations in a number of ways. Benefits plans can be a source of large liabilities (such as an under funded pension plan) or legal obligations (e.g., COBRA). And, as a crucial factor in employee compensation, mistakes or misunderstandings involving how benefits obligations will be handled can have severe employee relations repercussions. Therefore, taking steps to understand and make provisions for how the benefits plans of affected employees will be handled is crucial to the business transaction.

Any business owner entering merger/acquisition negotiations will need a thorough understanding of the affected employee benefits plans in order to assess the financial significance these plans bring to the transaction. For example, what is the funding status of any pension plan? Who will take responsibility for the COBRA coverage of employees terminated from the seller? Will the health insurer continue coverage for employees affected by the transaction? If health insurance coverage is self-funded, what is the extent of outstanding claims and potential liabilities? Which party will be responsible for any severance pay, accumulated vacation time or paid time off? Unforeseen liabilities associated with issues such as these can result in unwelcome surprises if discovered well into business negotiations.

Involving human resources and benefits personnel at the early stages of the business transaction can be one of the most important keys to avoiding problems. HR and benefits executives and staff are the individuals in a company with the best knowledge of the employee benefits plans. Furthermore, they understand the business strategy supporting the plans; how the plans fit into the company’s philosophy; compliance issues the plans create; and plan provisions and/or vendor-related issues that may be implicated in a merger/acquisition transaction.

HR involvement also is vital insofar as the role these individuals play in communicating M&A-related benefits issues to affected employees. Business transitions are a time when employees will be concerned about the potential for job loss or other changes in the status quo. Invariably, this becomes a time of stress for employees, with the potential for lower productivity, higher absenteeism and increased medical and disability claims. HR’s ability to answer questions, address rumors and clarify misconceptions will help keep these types of problems to a minimum.

Overall, employee benefits plans can present a myriad of complex, challenging issues in an M&A transaction. If dealt with upfront, early in the deal, the chances of these issues having a negative impact on the transaction are minimized. Involving HR staff in the beginning, and working with the services of business professionals savvy in M&A issues, also helps to ensure that employee benefits plan-related issues do not get in the way of a successful business deal. Let us help you with these and other complex Benefits issues. Contact us.

Your company, like most employers, probably has a prescription drug program that includes a drug formulary. You know how the formulary works with your co-pay design, “incentivizing” members to make cost-effective medication choices. Now, peek behind the curtain and see how the formulary works from the insurer’s side.

Purpose

Insurers (and employers) use the formulary to manage costs and to improve care. When a drug company introduces a new drug that is similar to other drugs already available to treat the same disorder, they are considered to be “therapeutically equivalent” or, work in the same way to treat the disorder. Given an equal choice, the insurer might offer only the less expensive drug in its formulary, i.e., “equal quality at a better price” or require higher co-pay for the more expensive drug. In the case of Lipitor versus Pravachol, both drugs belong in a therapeutic class called “statins.” They lower cholesterol by slowing down the body’s ability to make cholesterol. Drugs in this class include atorvastatin (brand name Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol) and simvastatin (Zocor). Consequently, the insurer may choose to cover only one or two of these drugs, based on their ability to negotiate favorable pricing.

Drug Selection

Insurers use a pharmacy & therapeutics (P&T) committee to select formulary drugs. The committee, made up of doctors and pharmacists, reviews the medical research on drugs within therapeutic categories. Within each category, they select the drugs that are “best in class” for inclusion on the formulary. The insurer then works to negotiate the best prices for the selected drugs.

The committee also tracks trends in side effects and outcomes of various drugs and may determine that a drug be eliminated if their ongoing research suggests that the benefits are not as real as the drug maker originally claimed.

In this way, the formulary protects plan members from drugs that are not performing as planned.

Cost

Insurers or, more frequently, sub-contracted pharmacy benefit managers (PBMs) negotiate the purchase price of drugs based on three factors: Volume, “class of trade” and “ability to move market.”

Volume. Insurers negotiate better pricing based on the volume of drugs they expect to purchase – the greater the volume, the lower the price. To the extent that a formulary delivers greater volume of one drug over another, the formulary creates a volume advantage that is useful in negotiation.

Class of Trade. Drug manufacturers must follow a “class of trade” system that provides:

• Lowest pricing to the federal government;
• Next lowest pricing to hospitals;
• Next lowest pricing to HMOs and other captive settings;
• Next lowest (or highest) pricing to purchasers for retail trade.

Insurers that qualify as HMOs or represent other captive populations will usually achieve a pricing advantage due to special status pricing.

Ability to Move Market. The formulary is vitally important in delivering market to manufacturers. When an insurer or PBM can tell Pfizer, manufacturer of Lipitor, that all (“all” is always qualified) prescriptions for cholesterol-lowering drugs will be written for Lipitor (versus Zocor or Prevachol), they are “delivering market” and creating a competitive advantage for Lipitor that Pfizer is willing to pay for through lowered pricing.

Outcome

Formularies can improve care through the careful, ongoing review of drug effectiveness results by the formulary decision makers, leading to best choices based on the latest research and use market forces to deliver lower pricing.

From its founding, the United States has been a multi-cultural and multi-lingual nation. This demographic reality has continued to the present day.

Statistics from the U.S. Department of Education (DOE) on language characteristics and literacy illustrate the linguistic diversity of this country. For example, according to one DOE report and based on an analysis of Census Bureau data, during the 1980s, the number of persons age five years and older who spoke a language other than English increased 41%. The most significant increases were in Spanish, Asian, and Pacific Islander languages. The report went on to state that among those who spoke a language other than English at home, 47% said they had difficulty speaking and understanding English. Furthermore, a DOE survey conducted in the 1990s reported that 10% of the population spoke no English at all before entering school.

A disproportionately high number of those reporting difficulty with English were age 25 or older, i.e., work-force age. Language diversity among workers can pose a host of challenges related to (among other things) the communication of employee benefits information.

What must an employer with non-English speaking workers do to ensure these employees truly understand their benefits programs? This question is best examined on two levels: What is required and what is good workplace communications practice.

The basic required communications piece of an employee benefit plan is the summary plan description (SPD). ERISA, the federal law that governs employee benefit plans, does not require that employers provide SPDs in any language other than English. However, ERISA regulations do require that, in some situations, an employer must provide within the English-language SPD a notice in another language that offers speakers of that language assistance in learning about their benefits.

According to ERISA regulations, the offered assistance need not involve written materials, but must be “calculated to provide [the non-English speakers] with a reasonable opportunity to become informed as to their rights and obligations under the plan,” and the procedures that they must follow to obtain such assistance. For example, the notice in the other language could include the name, telephone number, and office hours of the plan administrator.

When are employers required to provide this notice? If the plan covers fewer than 100 plan participants, and 25% or more of the participants are literate in only the same non-English language, the employer must provide the notice. For bigger plans, the notice is required if either 500 or more participants or at least 10% of the participants are literate in only the same non-English language. Thus, if only a few workers are non-English speakers, the notice is not required. Conversely, an employer may need to provide notices in more than one non-English language (for example, Spanish and Vietnamese) if the requisite number of workers are literate in only those languages.

Many employers with foreign language-speaking workers go beyond the SPD requirements to make sure that all workers understand their benefit programs:

• Translate some written materials into a foreign language. These might include highlights of the benefit programs, comparison charts, and enrollment forms. Companies that specialize in translation services for business needs could be contacted for this service.
• Open benefits meetings, including enrollment meetings, to family members. Younger family members in particular are likely to be more fluent in English. Having bi-lingual or separate meetings in another language also is an option, but this may involve more time and expense.
• Call upon employees who are fluent in both English and the foreign language to help those who have difficulty with English. This can be especially helpful at benefit meetings, where the rapid flow of a presentation or give-and-take of a question-and-answer session can sometimes be hard to follow.

An employer makes a huge investment in its benefit programs, and employees cannot appreciate these programs if they don’t understand them. Furthermore, employee benefits programs can be confusing, even for native English-speakers.

Contact us to explore methods by which your company can ensure that your employees have the opportunity to know their benefits. It’s an investment that helps employer and employees, alike.

Have you ever wondered how insurers determine small group (2-50 employees) renewal rates? Be assured that it’s not an arbitrary process. Yes, there is a method to this madness! Although there are various formulas used, generally insurers use the following factors to calculate your renewal rates:

General Health Care “Trend”
This is a baseline factor applied to all Group Health insurance renewals. Basically, “trend” refers to the change in cost of health care products and services, and how consumers utilize these products and services. New facilities, technologies, and procedures encourage more people to receive advanced services. The costs of these goods and services are expensive and increasing rapidly.

This component also includes “prescription drug trend.” More drugs are being introduced into the market and aggressively marketed. The costs of advertising and research/development of these drugs are significant. These rising costs, in combination with increasing utilization, all contribute to this baseline factor.

Keep in mind this “trend” also has much to do with your group’s geographic location. Just as home prices differ upon location, so do health care costs. Premiums in certain areas might reflect the higher cost of more people using state-of-the-art, yet expensive, treatments and services.

Group-Specific Medical/Health Factor
When permitted by state regulations, a carrier may adjust renewal rates based on the overall health of the people covered under your health plan. Your premiums may be adjusted to cover expected future claims costs. Depending on your state, certain rate caps might exist which limit the amount an insurer can raise premiums based on your group’s health status alone.

Most carriers use a “prospective” system, meaning that they look at medical conditions and diagnoses, which may affect the group’s claims experience in the coming year. Claims from the past year, which are resolved or if the risk is no longer present, are not taken into account using a prospective rating system.

Your renewal adjustment can also be positively impacted by good claims experience.

Group-Specific Characteristic/Demographic Profile
This component includes:

1. Age bracket changes (An employee or spouse turns 40, for example, moving them from the 35-39 bracket to the 40-44 bracket.)
2. Gender and coverage composition changes (The percentage of females and males changes or the mix of single and family contracts changes.)
3. Changes in the group’s location (Claims costs are geographically-based, so the rates may change if the company moves to a new locale.)

Group-Specific Administrative Expenses
This factor includes the fixed costs needed to administer the plan. The larger the group, the lower the expense load. For example, a two-person group would have a larger expense load, as a percentage of premiums, than a 25-person group.

So, what can you do to influence the costs? Ideas include adjusting your plan design and/or premium contribution to support more efficient utilization, encouraging employees to become smarter health care consumers through communication efforts, and promoting prevention and wellness programs. It’s a start at least.

Is your benefit department routinely tied up responding to complaints about medical claims for your company’s health plan members?

Medical claims problems are frequently the result of poor information and/or poor communication. Try some of the following methods to reduce the confusion, relieve the burden on your staff and improve the satisfaction of your plan members.

Remember, any time your staff works with personal health information, special care must be taken to assure that the information is treated confidentially and in compliance with all applicable HIPAA privacy rules.

Hold orientation sessions about health care benefits for members
It’s human nature to pay less attention to information that is not immediately useful. Consequently, many people who receive new benefit information do not absorb important changes if those changes do not appear to affect them at that time. Consequently, when the need unexpectedly arises, your plan member may not remember, for example, that she must place a call to her primary care physician within 24 hours of an emergency department visit.

One way to work around the “relevance/absorption” issue is to make effective use of scenarios during orientation sessions. The group leader should provide fictional examples of situations that illustrate new benefit rules. These examples will cause most people to apply the information to potential situations in their own lives and imprint the correct procedures or generate questions that will clarify information.

Hold orientation sessions about health care benefits for health care providers
This technique will not be practical in large city settings but can be very useful in smaller communities. If your company is introducing a new health plan into the community, everyone will need to incorporate new rules into their work. Invite the office staff of a local physician, hospital admitting and billing staff and others as appropriate to an orientation session with the insurer.

These staff members juggle many sets of health plan rules each day and, expectedly, cannot always keep information straight. They will be much more likely to integrate your new plan rules into their office practice if you have provided an opportunity for them to receive a full briefing and ask questions.

Select health plans that offer interactive Web sites
Medical claim problems often occur because the physician office or hospital admitting department has no way to verify eligibility or ascertain the specific rules related to your company’s plan. Health plans with interactive websites allow providers to go online and check eligibility, determine special rules, note any changes to the policy benefits, etc. This connectivity solves many of the potential medical claim problems.

Establish a regular meeting with the insurer to review medical claim issues
HR staff should keep a log of all medical claim complaints and status. Persistent problems should be turned over to the insurer with direction to resolve. In general, this technique keeps your HR staff as an intermediary so they are aware of problems but provides for the appropriate transfer of those problems to the insurer in a forum that requires follow up and reporting back results.

Data collected during this process, e.g., number of complaints, time to resolution, etc, can be useful evaluative tools. If your communication with the insurer is facilitated by a third party insurance broker, be sure that you have an agreement with the broker that all health information will be handled in compliance with HIPAA privacy rules.

HR as Advocate
Your staff will always play a middleman role for plan members because they are your members’ advocates to the health insurer. However, using these techniques should reduce the referee burden on your benefits group.

An important federal law imposes certain obligations on many employers to continue providing health care coverage to an employee and dependents, if applicable, in the event of a change of employment or job status.

This law is often referred to as “COBRA” – The Consolidated Omnibus Budget Reconciliation Act of 1985. According to COBRA, if an employer provides health care benefits to an employee and there is a change in that employee’s job status, the employer must afford the ability to continue coverage under their employer’s group health plan, at the employee’s expense. The COBRA continuation requirements apply to all of the “core benefits” provided under any group health plan that furnishes medical benefits to employees and their dependents, regardless of whether the plan is insured or self-funded. COBRA does not apply to employers who have less than 20 employees.

COBRA was designed to address concerns about Health insurance portability during periods of unemployment and labor force withdrawal and in situations in which a worker leaves, or would like to leave a job. Under the rules, employers have important obligations to both apprise the covered employees and other qualified beneficiaries of their rights and to continue to supply the Health insurance coverage upon payment of the appropriate premium amount. The continued coverage must, in most cases, be supplied after the occurrence of a “qualifying event.” The premium charged by the employer can be no more than the employer’s actual cost, plus 2%.

An employee and his beneficiaries are eligible to elect COBRA only if they were covered by the employer’s health care plan immediately prior to a “qualifying event.” A “qualifying event” could be any of the following:

• Termination of employment
• Reduction in work hours
• Employee’s death
• Employee’s divorce
• Loss of dependent status
• Medicare entitlement
• An employer’s filing of a bankruptcy proceeding (retirees and certain dependents only).

The most common qualifying event is the termination of employment. An employer is obligated to provide an employee with COBRA benefits in case of both voluntary and involuntary termination as well as reduction in work hours. Individuals who were covered by an employer’s group health plan are eligible to elect COBRA upon the occurrence of a qualifying event, no matter how long or short a time they were in the employer’s group health plan.

The time period for which continuation coverage must be offered by the employer varies. In the case of termination of employment or reduction of work hours, the employer is obligated to provide COBRA coverage for 18 months after the qualifying event. In case of the other qualifying events listed above, the coverage has to be provided for 36 months.

To fulfill COBRA obligations, it is the employer’s responsibility to notify the plan administrator (of the group health plan) of a qualifying event within 30 days of the actual event or by the date that the employee will lose their coverage, whichever is later. The employer should then see to it that the plan administrator notifies the beneficiary and his/her dependents, within the next 14 days, of their rights to continued coverage under COBRA. If the employer does not have access to COBRA administration services, the employer must ensure that the employee is provided with written notice of their rights within 44 days from the date of the event. Qualified beneficiaries are given a certain period of time (the “election period”) to elect continued coverage. This period lasts for at least 60 days, and may begin on different dates, depending on when coverage would otherwise be lost and when notices are given.

COBRA coverage is considered advantageous to most workers, as it allows them to continue coverage even after leaving or losing a job. Though they can be required to pay the entire entire premium, they can generally realize significant savings compared with the cost of purchasing equivalent insurance from the private insurance market. This is especially true for older workers, particularly those suffering from pre-existing conditions.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) was passed in 1986 to provide opportunity for continuation of group health coverage that would otherwise be terminated when a worker loses their job. The law covers group health plans maintained by employers with 20 or more employees. It applies to private sector plans as well as those sponsored by state and local governments. The only organizations with 20 or more employees whose plans aren’t covered by this law are those sponsored by the Federal government and certain church-related organizations.

The law provides for six types of continuation coverage notices that employers must comply with:

1. General COBRA Notice — A general written notice of COBRA rights and responsibilities must be given to each covered employee and spouse, if applicable, within 90 days of the date the individual first becomes eligible for coverage. It must contain the name of the plan and the name, address, and telephone number of the person who can provide more information about the plan. It must explain the plan’s requirements regarding the responsibility to notify the plan administrator of certain qualifying events and the necessity for keeping the administrator informed of address changes for participants and beneficiaries. It should also contain a statement that the general notice does not provide a full coverage description and that more information is available from the plan administrator and in the Summary Plan Description.
2. Employer’s Notice of Qualifying Event to Plan Administrator — The employer must notify the plan administrator in the event of qualifying events such as a covered employee’s death, termination of employment for any reason other than gross misconduct, reduction in hours, Medicare entitlement, or Chapter 11 bankruptcy proceeding. If loss of coverage occurs on the date the qualifying event occurs, the notice must be given within 30 days of the qualifying event. If loss of coverage occurs after the qualifying event, the notice must be given within 30 days after the loss of coverage.
3. Qualified Beneficiaries Notice of Qualifying Event — A covered employee/qualified beneficiary may be required to notify the plan administrator about certain qualifying events such as a divorce or legal separation that results in a loss of coverage, a child’s loss of dependent status, a second qualifying event, or Social Security Administration determination of disability. In general, such notice should be provided within 60 days of the later of the qualifying event date or the loss of coverage due to the qualifying event. Plans must establish reasonable procedures for the furnishing of the listed notices to the plan administrator.
4. Election Notice — The plan administrator must provide a written election notice to each qualified beneficiary within 14 days of receipt of a qualifying event notice or 44 days of the qualifying event if the employer is also the plan administrator. This notice must outline specific information as demonstrated by the Department of Labor’s model election notice.
5. Unavailability Notice — If the plan administrator receives a notice of a qualifying event, second qualifying event or Social Security disability determination, and determines that the individual is not entitled to continuation coverage, the administrator must give the individual written notice that continuation coverage is unavailable. This notice must explain why the individual is not entitled to continuation coverage. The deadline for this notice is the same as the deadline for sending an election notice.
6. Early Termination Notice — A written notice to the individual that continuation coverage will end earlier than the end of the applicable maximum period of continuation coverage. It must explain why coverage is being terminated early, the date of termination, and any rights the individual may have to elect alternative group or individual coverage.