DeKalb County commission approves creation of two-plan health benefit option; sets key deductibles and co-pays

DeKalb County commissioners voted May 21 to have Apex Benefits produce two employee health plan options — a preferred-provider organization (PPO) and a high-deductible health plan (HDHP) paired with a health savings account (HSA) — while staff and benefits consultants were directed to finalize stop-loss and transplant insurance and to model employee contribution scenarios ahead of the July 1 plan start.

The commission’s action formalizes a plan design the county’s benefits advisers and HR described during a lengthy discussion about premium equivalents, contribution strategies, pharmacy tiers, telehealth and employee education. The choice gives employees a lower-premium HDHP/HSA option and a PPO option with first-dollar co-pay coverage, officials said.

The vote matters because it sets the framework for open-enrollment materials, employee communications and IT configuration needed before the July 1 effective date. Commissioners also asked staff to model multiple contribution splits and potential county contributions to HSAs for final decision by the end of next week.

Apex and PHP representatives and DeKalb County HR staff presented details of the proposed design. The HDHP would use an embedded $3,500 individual deductible and a $7,000 family deductible; the commission was told the individual maximum out-of-pocket would be about $5,000 under the proposed structure. "The plan design that we laid out in the previous meeting, was a $3,500 individual embedded deductible, $7,000 family deductible," one presenter said during the meeting.

Under the county’s proposed structure, the PPO would provide co-pay coverage for routine office visits from day one, while the HDHP would require members to satisfy the deductible before first-dollar co-pay benefits apply. "If you’re on an HSA plan or high deductible health plan, you’re not eligible for first dollar coverage until you reach your deductible," a benefits presenter said.

Commissioners and staff discussed specific co-pay amounts reflected in the presentation. The group settled on raising the primary care office visit co-pay from $20 to $30 and setting a specialist co-pay at $60; other co-pays in the presentation were left unchanged. Pharmacy tiers in the proposed design mirror the current plan: Tier 1 (generic) $10, Tier 2 (preferred brand) $60, Tier 3 (nonpreferred brand) $90 and specialty $250, with a 90-day retail multiple (2.5) retained.

HR staff and Apex said they are still finalizing two technical pieces: a stop-loss arrangement (to limit employer liability for very large claims) and a fully insured organ-transplant policy that would sit on top of the self-funded plan to cover transplant costs. Commissioners asked staff and the vendors to complete those negotiations and return with final premium equivalents and modeled employee contribution scenarios.

On contribution modeling, staff described current employee payroll contributions as roughly: employee-only 7%, employee-spouse 11%, employee-child 10% and family 14% of premium, and presented scenarios showing how that county share would change under higher employee contribution splits. HR noted these percentages will be adjusted once final premium equivalents are available and after the commission picks plan design details.

Presenters described member-facing tools and vendor services intended to reduce cost and improve access: a provider finder and cost estimator in the PHP Freedom network (which includes local hospital systems), telehealth options (one per-visit Parkview solution and a PEPM Call-a-Doc option), and communications/training for employees during open enrollment. Vendors emphasized that employees on the HDHP could use telehealth at no cost and could shop for lower-cost lab and imaging providers where appropriate.

Commissioners asked vendors and HR to prioritize timely materials for employee education. A motion to have Apex create the two plans using the proposed column 3 ("Proposed 1") design and network (PHP Freedom) carried on a voice vote. Staff said they will return with modeled contribution scenarios and final premium equivalents (with stop-loss and transplant pieces included) at a follow-up meeting.

Discussion versus formal action: the meeting combined discussion of plan design options, direction to staff/vendors to finalize stop-loss and transplant arrangements and the formal vote to have Apex produce the two plans. Several commissioners emphasized concern about balancing taxpayer cost and employee affordability; one commissioner asked staff to examine the county’s underlying utilization trends in coming months.

Details the commission directed staff to provide before the next decision included final premium equivalents incorporating stop-loss and the organ-transplant policy, multiple employee contribution scenarios (including potential county HSA contributions), and open-enrollment communications and scheduling for on-site employee education.

The commission meeting also included discussion of lab-network differences and advice that employees could save money by using lower-cost LabCorp locations rather than hospital-based labs — a point vendors and HR said they would emphasize in employee outreach.

The commission’s action does not change final premium equivalents, employee contribution percentages or any county HSA contribution amount; those remain contingent on the follow-up modeling and final stop-loss/transplant quotes staff requested to complete.

What’s next: staff and Apex will return with the final premium equivalents, the completed stop-loss and transplant pricing, and a set of employee-contribution scenarios and communications materials for commissioners to review before implementation and open enrollment.