Transcript

0:00:04And we're recording. Thank you. Good afternoon, everyone. I'm Ashley Stolzman, and I'm joined by Commissioner Martha Lochamin, and we are here for the afternoon meeting on August 27th, 2026, at the Board of County Commissioners. Commissioner Levy is excused. We're here this afternoon to have a public meeting on the Benefits Advisory Board benefits workshop for 2027. We're going to have a presentation from Emily Koop. And hear from board members about 5 decisions that the board needs to make this afternoon and any questions or comments that board members have as well. So I will turn it over, I believe, to Emily Cooper. Emily's actually out today, so she won't be speaking. I think we're gonna let Kelly Schultz start us off. Great, sorry about that, Kelly. And so we'll have— and just each person, when you speak, you're going to need to say your name for the record.

0:00:54Okay. Thank you. Stephanie Hyatt from the Benefits team. Thank you so much. And so, Kelly, thank you very much for covering for Emily, and we'll turn it over to Kelly. No problem. Thank you. Good afternoon. My name is Kelly Schultz, the 2026 BAB chairperson, and I'm honored to speak on behalf of the Benefits Advisory Board today. Joining me online are members of our board, which includes representatives from all across of the county departments and divisions. Before we dive into the numbers, I want to take a moment to acknowledge the dedication of this group. From March through August, the BAB meets monthly to analyze complex financial data, evaluate benefit programs, and most importantly, gather direct feedback from our colleagues. Every vote we took and every recommendation we are bringing to you today was weighed carefully through two vital lenses: protecting the financial health of the county budget and supporting the physical and financial well-being of our employees. As you know, healthcare costs across the nation continue to rise, driven by inflation, provider contract shifts, and surging pharmacy trends, and Boulder County is not immune to these pressures. Our 2025 claims ran over budget, and based on our 2026 performance through June, we are facing projected medical plan cost increases.

0:02:12Rather than reacting at the last minute, the BAB has taken proactive steps throughout the spring and the summer to control costs responsibly that will be presented to you for your decision today. We added high-value, cost-effective care by voting to introduce Marathon Health near-site clinics, clinics for 2027, giving employees access to $0 copay primary care, labs, and generic medications. We are also proposing to eliminate underutilized vendors, hopefully cutting wasted administrative overhead, and we have exercised strong fiscal restraint by declining or deferring costly program expansions to ensure we didn't add any unnecessary spending into the plan. Guided by our racial equity impact assessments, we have structured clear options that we will propose to you today in hopes of softening the impact on employees while still delivering meaningful savings back to the county. And at this time, I'd like to turn the presentation over to the benefits consultants from the NJ Companies, and they will walk you through the detailed year-to-date performance data, updated forecasts, and the exact strategic recommendations recommended by the BAB for your final decisions. Thank you.

0:03:26Thank you, Kelly, and thank you to all the BAB members for the hard work that you do every year. I'm sure we may have questions for you throughout, but that was a great intro, and we'll turn it over to, I believe, Courtney. Yes, thank you, Kelly. Thank you, Commissioners. I'm going to share a presentation in a moment, and I believe the county has a statement that needs to be read before I do that. Thank you so much, Courtney. Hello, this is Johnny Sloss with Commissioner staff. For the upcoming presentation shared through Zoom, anyone participating in Zoom who needs or desires captions should turn on the captions in the Zoom app at this time and leave them on until the presentation is over. Thank you. Thank you, John. All right, and with that, I'm going to share.

0:04:11And wonderful. It's wonderful to be back in touch with all of you today. Again, my name is Courtney Hutchison, and I'm with the MJ Companies. I understand we're working on a bit of an abbreviated timeline today in terms of the duration of the meeting. We will do our best to complete the meeting in a shortened amount of time, and we've taken the liberty to move some things into to the appendix in that spirit. I'm going to just quickly scroll through a couple of comments. As John alluded, this, this presentation is fully accessible. If you do require a different format or accommodations, there's information on the screen and in the posted copy on how to request that from the county. And just as a reminder, the county is currently in active negotiation on a collective bargaining agreement, and this is just a disclosure that those conversations are ongoing. Before we jump into our presentation, I would like Jill Dietrich, who's the interim budget officer, to share a few opening remarks as well. Jill, over to you.

0:05:07Good afternoon, Commissioners. Jill Dietrich, budget manager serving as interim budget officer in the Office of Financial Management. If you go ahead and move to the next slide, I'm just going to start us off today by setting the scene, providing a very brief high-level summary of the net position or fund balance in our health and dental fund. As noted on the slide, we ended the fiscal year 2024 with $14.5 million of fund balance and utilized an additional $3.2 million of that balance in 2025. This leaves the county with a total net position of $11.2 million for the prior fiscal year. So the prior fiscal year, so although we remain in a healthy space with a little more than $6 million of surplus above that required minimum reserve that's noted We do continue to monitor plan performance and the current trend of annual fund balance utilization that Kelly also kind of alluded to in her remarks. Unless there are questions on this high-level financial picture, I'll kick it back over to Courtney to walk through MJ's information. Thank you, Jillian. Back to Courtney. Thank you, Jillian.

0:06:17All right, moving right along. We've already heard from Kelly, so I am joined today by 4 other MJ colleagues. You will hear from all 4 of them likely at some point today. And we are joined today by not one but two members of our analytics team, both of whom are actuaries. So get ready for some numbers in that spirit. Just to orient you with the agenda, Kelly, you did a fantastic job of really setting the stage for the work that we've been doing in partnership with BAB all year. We're going to take a moment, though, and orient the audience today with what's happening beyond the county and, candidly, beyond Colorado in terms of national market trends impacting healthcare primarily and employee benefits more broadly. And then after that, we'll— we'll zoom in a little bit onto how the Boulder County self-funded medical and pharmacy plan has been performing year to date, which feeds quite nicely into the projected cost for 2027, the recommendations being made, how that all translates into employee premiums. And then we'll certainly allow time for discussion at the end before any sort of recommendation approval is requested. We will also pause periodically for questions as we go. And because we're virtual and I'm sharing my screen, if I don't see a hand or an insertion, but by all means, just please interrupt me

0:07:34if you have a question. All right, so as Kelly alluded, there are 5 decisions that we're going to be seeking from the commissioners today, and those are summarized here on this slide. The first 4 are recommendations that we are going to be proposing to you on behalf of BAB, and Kelly did a nice job teeing all of these up. And then the 5th is really an alternative to BAB recommendations. Recommendation number 2, both of which are related to the benefit plan designs that are offered to employees and their dependents at the county. There's just an alternative that we wanted to bring to the table in addition to the BAB recommendation. So it would be one or the other, but not both, if that makes sense. So just wanted you to have these in the back of your mind as we go through the discussion. All right.

0:08:24So as mentioned, let's talk about what's happening nationally. In the employee benefits and healthcare market. So, as you are probably reading or hearing or chatting about with colleagues, cost continues to be front and center with respect to healthcare in America. And we wanted to take a moment and talk about what's really driving cost to continue increasing. And we've, you know, there's many, many reasons, but we can really bucket those into 4 key categories that you see on the screen here: prescription drugs, Everything from the increased cost and use of GLP-1s and weight loss medications, as well as high-cost specialty medications to now treat and often cure diseases that were once not curable, such as cancer and other conditions. Chronic conditions continue to drive a lot of costs for the healthcare system in our country. Again, cancer, musculoskeletal, diabetes, cardiovascular, and obesity are all among the drivers in that category. Behavioral health, we talked about this last year. I, I still do view this as a positive.

0:09:33Behavioral health claims continue to increase significantly, which is fantastic that folks are finally getting the care they need on a national level, but that does obviously come with some cost. And then lastly, inflation. Healthcare is not immune to inflation, just like every other business and every other industry, and everybody that is tangential to the healthcare market is impacted by the same inflationary pressures, which has been forcing costs down to everybody else. In terms of magnitude and the, you know, how much is each of these impacting cost, not only nationally, but for the county as well, we've included this helpful speedometer indicator here. And as you can see, the one driving the bulk of the cost trend inflation is pharmacy, followed closely by chronic conditions inflationary pressure, and then behavioral health would be fourth. And I mention this only because when Kyle and Paige get into the forecast for your plan, We take all of this into account. We take your own experience as well as the experience of the ecosystem around you in determining what things are going to— or projecting what things are going to cost for you next year. So I thought— we thought this would provide a helpful baseline.

0:10:46Drilling down a little further, because the county's plan is self-insured, you purchase a product called stop loss. Stop loss is the the only insurance you actually purchase externally with respect to your medical and pharmacy program, and that is to protect very large and very catastrophic claims that may be incurred by your membership during the year. And just to give you a, a sense of what's been happening with those broader costs I talked about on the prior slide, what this image shows is when we look at the stop-loss insurers across the country, what has been happening to their losses. And as you can see, just last year, the amount of claims that the stop-loss insurers have had to pay jumped significantly relative to the premium they were collecting. That is, that is indicative of what's happening with, with rising costs, and that is also indicative to what's happening to the cost of this insurance. And you'll see how we factored this into our projections for you later. Now, one of the main reasons why the stop-loss insurance market is losing money is because of the phenomenon happening on this next slide. We are seeing greater and greater frequency of claimants, individual and individuals incurring over $1 million in claims.

0:12:06And this is national. Again, we're still talking national statistics. Knock on wood, the county has not necessarily experienced this, although you did have a claim that come close a couple of years ago at about $900,000 in a single year. So, you know, 2 years ago nationally, we just didn't have that many individuals that were incurring those kinds of dollars. Through Q1 of '25 alone, there were 329. And a lot of this has to do for cost to treat cancer and also the severity of other conditions that are incurring. So this is the market in which we're living and functioning, and these are the protections that we need to make sure are in place. Place for your plan as well. Before I move on to sort of levers that we're seeing employers pull to combat all this, any, any just general questions about any of the market data I just presented? No, there are no questions yet. Thanks, Courtney. Keep— Thank you. All right. So you might be wondering, well, goodness, with all this cost, what can we do? And we will get into the recommendations and levers that are, that are being recommended for your consideration today, but we thought it might just help to show you what are all the levers available and what's becoming more and more common and popular for us to be speaking speaking to other

0:13:18employers about. So, this is intentionally blank for a moment just to orient you with the spectrum. But again, there's also 4 key levers that plan sponsors like the county can pull to try to mitigate cost. Everything from, you know, which providers people see through plan design or through the network, how much you charge employees through plan design or their premiums, and then how much you invest in their health in the first place to ensure that they stay healthy and avoid certain catastrophic conditions. And as you move from left to right along these spectrums, as you can imagine, you know, your ability to control costs and save money as a county goes up as you move to the right option from your employees. And so it's, it's that delicate balancing act. Now what I'm going to pop up on the screen next are icons of all the things that can be done in each category, and pay attention to the pink star because that is where the county falls today.

0:14:15On this spectrum. So I'm not going to talk about all of these. These are just a variety of things that can be done, but I think one takeaway here for me is if you look at the first 3 levers, the county has stayed sort of left of center, if you will, in terms of the levers that you've decided to pull, although there are much more aggressive levers that can be pulled to achieve higher cost savings. It just hasn't been contemplated or of interest for the BAB to recommend at this time. The exception being the county's investment in employee health. You have been an innovator and and on the bleeding edge of this for years, and you continue to invest a lot of money in, and resources and passion in ensuring your population remains healthy. You will hear today from BAB recommendations, particularly in the provider steerage area.

0:15:03Kelly mentioned this with the introduction of Marathon Health, and we'll talk about, like I said, things that we're exploring with other clients that are very much further to the right because of the need to save money. All right. And if there are no questions, that was my very quick market update, and I'm going to turn it over to my colleague Kyle Sullivan, who's an actuary and associate director of analytics in our Colorado office, to talk more about how your own plan is performing year to date. Thank you, Courtney. Kyle, go ahead. Thanks, Courtney. So as we— Kyle, we need you to say your name for the record, please. Oh, yes. Thank you, Commissioner. My name is Kyle Sullivan with the MJ Companies. We'll start here reviewing how the actual county costs have trended over the last several years. So as a self-funded employer, your medical plan since 2024 has grown at a slower rate than market.

0:16:01So during this 2-year period, actual plan spend in the form of claims and administrative fees have grown by about 11.2%. Or about 5.5% annual trend per year. The market during the same time period has grown by almost 19%, or an annual trend of about 9.0%. So the efforts in investing in employee wellness and balancing plan design have slowed the growth of the county's plan spend during this 2-year period. Projected costs through the end of 2026 shown here are very close to what's already happened. So what we'll review on the next slide is how are we trending year-to-date compared to where our self-funded budget has been set. Do you have any questions on this slide? No, we'll let you know if we have questions. Thanks, Kyle. Keep going. Thank you. So with data through the end of June, so half of the year, currently our medical pharmacy plan has a total plan spend that has exceeded our self-funded budget by about 10%. As Kelly mentioned earlier, 2025, we also had a deficit of about $3.2 million. The plan ran at about 14% above budget. Currently, with data through June, as you can see in the top left, is our budget variance is $1.6 million. Projected through the end of the year, this would be about $3.2 million.

0:17:35Of note is the plan's enrollment in the top right has been fairly consistent with a slight decrease of about 3%. And one of the cost drivers that we're experiencing this year in the, the right middle are the large claimants. So members with claims, cumulative claims over $225,000. There have been 6 members in 2026 year to date compared to this time, compared to in June 2025. Only 4 members. So it's almost an additional $800,000 related to claims just from these 6 members that had not happened last year. In the lower left-hand corner, I did want to call out the employee plan spends. Based on our changes this last year, moving our administration over to Cigna and a direct contract with CVS Health, we now have additional data provided in this report that was unavailable to us last year. So when you see a 71% increase in employee plan spend. That is really more a function of getting the full complete picture now, where previously we didn't have data related to behavioral health claims. We didn't have data related to the actual pharmacy employee out-of-pocket costs.

0:18:46And when I mention out-of-pocket costs, what I mean are deductibles, coinsurance, and copays, things that employees are spending at point of service and not related to what's coming out of their paycheck. Next slide, please. When we're looking towards 2027, we want to understand how your risk profile compares to overall— to the market and to our book of business. So based on our book of business, as you can see in the top left, the different types of medical episodes, the profile of risk is very similar to what we've seen across our book of business. Comparing your total plan per member per month claims to our book of business, you're very close with about 4% above our book of business, which is very in line with what we're seeing. From a cost driver perspective, the all conditions align with our book of business. One notable omission here is that there are no cancer claims as top episodes.

0:19:50So we expect been in a fortunate position from that perspective. And the one that kind of jumps off the screen, pregnancy and childbirth, is related to just one or two members who had higher cost claims this year. So that can be skewed from one year to the next. Again, we're comparing data through June 2026 to data through June 2025. Andrea, would you be able to comment on this slide? Yes, yes. Thanks, Kyle. Good afternoon, commissioners. My name is Andrea Crone. I'm on the MJ team supporting Boulder County, and this slide summarizes key utilization data of many of the other programs that you currently have in place at the county. I would like to highlight just two of these programs in particular. The first here is Color, which is a, a new program that the county added this year.

0:20:44It offers those at-home cancer screenings and cancer support services. So far this year, the utilization and the feedback on this program has been very positive, and that is exactly what you want to see on a brand new program in the first year. And we will continue to monitor this, but so far we are very happy with the utilization on this program. The other one I want to highlight here really quickly is MindCo. MindCo utilization continues to be very low every year since it's been put into place into 2024. As you can see for 2025 and 2026, At most, there have been about 8 individuals using each of these programs. And since 2025, there have been no users who have reported quitting tobacco. So this is far below the level of utilization that we like to see and that is needed for a program to have a meaningful and positive impact for your employees and workforce. I have a question on— was it Andrea or Andrea? Yes, Andrea. Andrea, sorry about mispronouncing your name. That's okay. Thank you. That information on MindCo is just really different than what we heard last year from Emily, and I wonder if you can reconcile the difference in information. Yeah, so last year we were comparing, and I apologize, I'm looking at my, my information over on

0:22:00another screen here too on MindCo. So overall what we did is we looked at total enrollments versus total engagement, and last year we were looking at '24-'25. This year we're just looking at '25-'26. Overall, what we did see, and, and going back to MindCo to get some additional information from them on how they look at enrolled versus engaged is a key factor. I believe that may be what you're referencing. So there is a difference. So enrolled means the number of individuals who actually went into the MindCo system, requested a virtual reality system to be delivered to their home so that they could then use the program. Engaged is referencing the number of people who actually use the program. So they download downloaded the app, they engaged in one or more of those virtual reality programs. So that number is very, very different.

0:22:53So for example, you had a few hundred people who've actually enrolled, had the devices delivered to their homes, but then only a handful of people, 7, 8 or so, who actually went in, downloaded the app and accessed the program. Does that help answer your question? It does. Thank you. I asked a number of questions last year about, you know, whether this was a benefit people were using or if they just tried it, and I felt like I got a very different answer. And I was hearing last year that it was very important for people, particularly trying to quit smoking, but this information makes it look like it's not. So I'm just trying to reconcile the difference in that information. Yeah, absolutely. We did— I did sit down with MindCo just to get some additional information on how they were reporting the data. And so when we really looked at it and looked again at that enrollment versus actual actual engagement, those numbers were quite different. So there does seem to be some interest in the program.

0:23:49People are logging in, they're ordering the systems, but then they're not actually sitting down and using them. So, you know, or maybe try— or maybe they tried it and it was not effective. Yes, that's also very possible. I think the big thing on the tobacco cessation is really seeing for— and this is what MindCo has reported to us directly for 2025 and 2026. They're saying no users have reported quitting or reducing their smoking from the program. And I know that that was a key piece as well. Thank you. Of course. Other than those two programs, you know, you're— and other than MI'NCO specifically, we continue to see really good engagement and utilization in all of these programs, and we'll continue to monitor. Thanks, Andrew. Thank you so much. This is Courtney Hutchison again. Before I turn it back to Kyle, I just want to quickly remind everybody that we're going to be getting into some really specific cost figures now that are specific to the county's benefit— employee benefit programs, and even more specific to medical and pharmacy. This is— so when you see dollars and increases over the next several slides, just a reminder, this is not payroll related.

0:25:06This is not salary expense related. This is very specific to the self-funded programs and the benefits programs as a whole. And with that, Kyle, I'll turn it back to you. Thank you, Courtney. So we kind of set the stage for 2026. We talked a little bit about how the plan has been running compared to budget. We reflected a little bit on how 2025 ended over budget and where we're projecting 2026 over budget. So when we look look towards 2027, not only do we have to adjust our cost projections for where we think costs will land, but we have to, to make up for the gap that we're currently experiencing in this year. There are 3 scenarios we're going to look at. The first is status quo. So status quo represents the minimal amount of change to all employee benefits. So specific— excuse me— to medical and pharmacy plans. So this represents only changes to the IRS-mandated plan design related to the high deductible plan. Based on our current 2026 funding and our projected annual plan costs of $36.9 million, there would be a 16.6% increase to budget rates in order to fund at where we expect plan costs to be in 2027. This represents a $2 million increase over our year-end projections through 2026.

0:26:34The next two scenarios we'll look at are at first the BABB recommended scenario and then the MJ recommended scenario. So the BABB recommendation, we, during our discussions, we strive to balance the change, any changes to benefit design with also increases or shifts to payroll. What we're discussing here are total plan costs, represent all claims and administrative fees related to the medical pharmacy program and do not include any offsets from payroll deductions. Based on the recommended changes from BAB, the required increase would reduce to 14.6% in order to cover 2027 expected costs. The annual plan costs for 2027 in this scenario decreased by $600,000 to $36.3 million and are $1.4 million over our projected 2026 actual costs. The additional recommendation we wanted to consider, it, it follows the same path of the BAB recommendations and then expands on some additional plan design changes. These additional changes reduce that required increase to our budget to 13.4% over our current 2026 funding levels. Annual plan costs are then $35.9 million, which is $1 million above our projected 2026 actual costs.

0:28:12Next slide, please. So for our recommendations, we, we've already kind of teed up that plan design changes are on the table. Also, we've introduced this new vendor in Marathon Health. Marathon Health does provide primary care in a clinic setting, which is an important contributor to how we want to manage and continue to invest in employee wellness and proactive health. So what we've— what we've— what we're showing here in all scenarios, status quo, the recommended BABSS scenario, and the recommended MJ scenario, they all include Marathon Health as an additional partner. We're showing a cost-neutral impact to plan spend, but it's important to note that Marathon Health does represent a significant saving opportunity to employees at point of service. So members on both plans would be able to access a Marathon Health clinic and pay for primary care— well, not pay at all. It's $0 primary care. And this was voted on and very landslide.

0:29:24He had a 16-3 vote in favor of adding Marathon Health. It's part of our strategy to help reduce barriers to care while pairing that with the consideration of additional plan design changes. Kyle, what were the concerns of the 3 members that didn't support it? Great question. Courtney or Andrea, can you— do you have those? Yeah, I was going to ask— this is Courtney. I was going to ask Andrea or Jamie, since I'm sharing my screen, in the appendix we have the racial equity detail on this discussion. If one of you wouldn't mind looking at that and chiming in with some of the concerns, that would be helpful. Unless you know off the top of your head. Yeah, I have it up on my other screen. Hi, Jamie Westbury with the MJ Companies. I'm the client executive working with Boulder County.

0:30:15So I think the primary concern based on the REAC discussion is maybe just based off of the comments. That there is an engagement-based fee and, and they may have been concerned that there will not be enough savings over time. Additionally, they may have been concerned about access, which I'll talk about in detail in one of the later slides. But there are some particular areas that today do not have a center within 10 miles. So we'll— we can deep dive in that. It's essentially the Longmont area. But when we look at the access and parameters that we typically look at to consider strong access, the county does look very good in terms of access. So those are likely the two primary concerns. Thank you. Thank you. Ready to move on, Kyle? Let's do it. Okay. So these next two scenarios, so we'll first start on the BAP recommendation with the additional plan design changes.

0:31:38There includes an increase to employee deductibles and also increases to the out-of-pocket maximums. While we're trying to balance indexing the plan to be able to keep pace with inflationary pressures with continuing to offer robust benefits. So based on this, there's a $600,000 savings opportunity compared to our status quo forecast. The additional recommendation that we're putting forth, it has the same increase to deductibles but a larger increase to the out-of-pocket maximum in an effort to help curb costs and set the plan up for long-term success. Again, in this inflationary environment, we wanted to consider both options just given what we know about the many initiatives and budgetary pressures that the county has been experiencing. Kyle, thank you. This is Courtney Hutchison again. One thing I would note is if we did include the BAB vote at the bottom, as you can see, it was a fairly close 12 taking the lead in terms of what became the ultimate recommendation, 10 voting for the other set of plan design changes that MJ would concur with. And so we, given how close that vote was, we wanted to bring forth both for your consideration today, and we'll go through the details on what these changes are here in a moment. Before we do that though, any questions on any of the numbers? I, well, Jillian, I think

0:33:14perhaps after you present it, that we may or may not have any questions, but Jillian, just I think understanding from your perspective what that does to the bottom line or risk for the county, if that's something you have looked at or could make a recommendation to us on. And Commissioner Litschman also is off mute and she may have questions also. Yeah, thank you. Do you want to have Jillian Gohm speak first? So we have not put forward a recommendation from OFM on either of these. Plan design changes, but certainly can come back with numbers on the end results for each. Okay, thank you. Thank you. Just a question, and if you're going to go into this, I don't know if there's going to be some more information coming in regards to the recommendations. So if so, just about the marathon that we— I don't know, I'm not sure what that is. Is read the text on the screen, but I'm just trying to figure out— also did hear the conversation.

0:34:21We are going to cover that in detail in just a moment. Yes, thank you. I believe it's the next slide. Okay, and then just so I'm understanding the slides, is— does this slide line up with the one we saw previously where it says, um, BAB recommends— recommends Yes. Yes. Okay. The previous slide, what we're showing in the middle here is the difference from status quo to the BAB recommendation is that $600,000 savings amount based on those plan design changes. And then on the far right, the MJ recommendation, the difference between the two is the $1 million. So you're absolutely correct. It does align with the— Okay. And then, so the question I'm wondering about is, Did you all work together with your different recommendations, or was this— that came together, they gave a recommendation looking, didn't see what you all were going to be voting to yourself?

0:35:14We did work with them. So they, they, so we had the vote in the, the bottom here. They saw both scenarios. There actually were 4 different scenarios that had different employee cost share. What we're looking at here is total program cost. So they, they did see and vote on the consideration of the additional plan design changes. I believe, as Courtney mentioned, due to how close the vote was and just the overall financial pressures given the current environment, we wanted to make sure we were at least discussing it with you so you understood kind of what was presented. Great, thanks. That's exactly right, and I— and this is one of those years where I feel we come to the table today wearing two different hats. We are representing BABBS recommendations. We are also the county's advisor and wanted you to know our point of view in addition to the BABBS.

0:36:16All right, given the question to dig deeper into marathon, Jamie, let's, let's do that next. I'll advance. Thanks, Courtney. Jamie Westbury with MJ again. So why advanced primary care and Marathon Health in particular? So we'll talk through this and I'll explain what exactly Marathon Health is. So Marathon Health is an advanced primary care near-site clinic. And what that means is you have providers focused on primary care, kind of work in an expanded capacity from your traditional model that is available at a local location. So near site just means it is not on Boulder's campus. They are tapping into various clinics spread across the metro area. There are 14 that are accessible to Boulder County members as of today. And, and that is where members go or can go. So it's an expanded option from the Aetna PPO network that's available today.

0:37:29But what is different about Marathon Health and Advanced Primary Care is it lowers the cost of care overall. So Courtney, you can bring up the first box for me. Um, because of the model, because they're able to more closely manage patients, um, the cost of care is lower than some of the alternative sites, in addition to lower than your typical primary care physician visit. Um, really what, what brought us— what drove us to bring this opportunity to the BAB is the savings opportunity that you see on the screen, that $2.3 million paid by the plan and the $1.2 million paid by employees. That's over the course of 2025. And what those numbers are capturing is any of the services that were incurred by all Boulder County members that could be redirected to a Marathon Health clinic. So there's some significant savings opportunities over the course of time as individuals continue to engage in care. And not only can they see a primary care physician, but they can also get some limited generic drugs dispensed as well as having labs completed.

0:39:01One of the next benefits is it helps minimize unnecessary urgent care and emergency care. Because it's an expansion of the network and individuals are able to get in more quickly to see providers, you're able to eliminate, and we've seen this across our book of business. So we can see it with our MJ clients who have implemented Marathon that their ER and urgent care utilization starts to reduce over time. In addition to reducing those unnecessary urgent care and emergency room visits, the time that members are able to spend with a provider in one of the clinics is significantly longer than your traditional model. If you walk in and visit a PCP today, on average, you're spending 18 minutes with a provider where the marathon clinic visits are 30 to 50 minutes long, really just enabling the provider to address more health issues more fully, see the patient, and help navigate kind of an expanded scope of their overall health. So that kind of takes us to the next reason for exploring advanced primary care and Marathon Health. That is, it reduces unnecessary specialty referrals. So in advanced primary care models, the providers are able to practice kind of at the top end of their clinic, of their licensure.

0:40:32So they can treat more conditions, really limiting the amount of specialist visits that members have to have, reducing the cost to the county, reducing the amount of time members are having to spend in provider offices because they're able to really kind of quarterback the care more appropriately. And then Marathon Health has what's called a value-based referral system. So when a provider is seeing a member and they're kind of to the end of what they are able to treat for, they utilize a healthcare navigation system called Garner Health, and it helps to identify and select the highest quality and I will say highest value providers so that when somebody moves into the specialty care system, they're getting the best care Over time, it is a lower cost with that specialist because they're not prescribing unnecessary procedures and they're just helping manage costs better.

0:41:37The next one ties in a little bit to some of the others. So increased access to care. I already mentioned this is an overlay to the existing network today. So individuals have a larger group to pick from for primary care. They do not need to go to an urgent care clinic because they can more easily get in for acute care for your colds, your flu, virus, things that you may not be able to get into your PCP for quickly enough or as quickly as desired. This stat is really most members are able to get in same day or next day compared with 20.5 days average wait time when you're talking about— that's talking about primary care specifically. So when somebody has a need, they can get in and get the issue addressed more quickly. Commissioner Stoltzman, it looks like you have a question. Well, I just feel like you're sort of using long coded language. And so are you essentially saying there are 14 clinic sites people can go to without within the network that wouldn't have a cost for them. And it is an optional thing that employees could use.

0:42:50Is that what you're describing? Yeah. Okay. And then you'll put the locations up at some point? Yes. Great. Yeah, I do want to hit just really quickly on two additional things. They do support chronic condition management and you already hit the nail on the head, no-cost care for members. So some savings in a world where Many things are being taken away and you're adding costs in terms of shifting plan costs when people see providers to members. This gives them an alternative option. So here are access stats. 97% of the population within 15 miles. We would certainly love that to be higher, but that's a phenomenal number to be 97% within 15 miles. 15 miles. You do have 56 within 5 miles. There are, um, I have, and it's in the appendix, the list of clinics. There is one right in Boulder.

0:43:48There is one in Broomfield, Arvada, um, Greeley, Northglenn. They are actively working to expand the network into the Longmont area. So that is one area they're looking to address, and that is a particular area where access is more limited to individuals. However, there is virtual care access through Care Anywhere, which is Marathon's exclusive virtual care offering. So everybody would be able to utilize that benefit, assuming it was appropriate, of course. And I will just call this out in terms of the discussion that we did have with Bab. One of the maybe limited concerns was that access. And so that's, that is likely why those individuals voted no. Um, other feedback we got from BAP, since I believe this is our last marathon slide, um, is they really appreciated that it's an added benefit in a world where so many things are being taken away, they're able— the county would be able to offer this, and employees can get access to care at no cost, which is really kind of a thing of the past. That applies not only to the hybrid plan but also to the consumer choice high deductible plan.

0:45:17So there are pathways through recent legislation that apply to Advanced Primary Care that allow this to be no cost regardless of being on the high deductible plan, and it doesn't disqualify them from contributing to an HSA. Well, thanks, Jamie. I think it looked like in the appendix what it said is like perhaps a concern was people wouldn't know how to use it, or it would like, you know, they wouldn't know, go to their doctor, go to this, and there was maybe a solution that was more communication. Were you planning to talk about that a little bit, about how people would learn about this and how people could learn about what their choice was to continue going to their doctor versus this if they wanted? Like, is that part of the comment? And yeah, yeah, so we don't have a slide on it, but absolutely happy to talk about it. In terms of communications, that will be a big part of the strategy, in particular in year 1. We will want to communicate heavily in MJ's open enrollment materials. We will make a big splash on the homepage of the microsite and ensure everybody sees that that is a no-cost-added benefit to them. We can add specific communications around kind of the network layering and that it is an alternative to

0:46:33their current primary care physician because we certainly don't want them disrupting their existing provider relationships if that is something that is working for them. But we want to emphasize for those who don't have one or maybe feel like it's a less than desirable experience that they have when they, when they do those visits, that that it's an alternative. So there will be kind of a stair-step communication in terms of how to use it, what to use it for, obviously where the locations are and all of that included. And then I know that the benefits team will be hosting their onsite meetings and I know they will be talking about it as well. Thanks. Any other questions? I did have couple questions on— thanks for the additional information, Marathon. Just looking online, it looks like it's Algonquin Anishnaabeg First Nation holders, which makes sense where we're at right now with insurance. Just have an understanding, I thought I heard you say no cost to employees, and then there was a previous slide that talked about $1-2 million, I think, by employee.

0:47:44There's services that could have been sent to a different clinic that they paid. So I'm just, I'm just trying to understand the motive of that transfer. And then I also just curious about the Mi'kmaq with that marathon clinic, just in regards to cultural competency and health equity, because that is earlier this morning. Just want to have an understanding, what is that? I was having a hard time— Courtney, did you get— I'll please, if you just wait, I'll summarize. I just was like waiting until Commissioner Litchfield was Is there an issue with sound? Is that what you're— Yes, yes, but I heard— I said I'll try to summarize the 2 questions. The first question is essentially if you go back in the slide deck, you'll see that $2 million number associated with the marathon. That's the potential savings piece of it. If you could explain that and like where that goes and like who benefits from that or how that would play in in the future. That's not exactly what Commissioner Luchmann said, but it was around explaining that $2 million number. That was on the slide. So maybe you go back to that slide and describe that more.

0:49:10You called it a cost, but it wasn't. And so just correcting on that. And then the second part of the question was, could you describe the cultural competency that's associated with Marathon? And like, is there Spanish language access? Like, what kind of care is it? And what competencies exist within their organization and structure? And if I got that all wrong, that was the best I heard, Commissioner Lutzman. So maybe you try again. Well, yeah. Just quick. Yes, it was in regards to the other slide, but I was asking about the one— I thought there was a $1.2 million that staff would be charged in cost, and so I was trying to connect no cost to what that cost would be. So same slide, I think a different number. And then I was looking at cultural congruency versus just competencies. Um, so thank you. Yeah, so the $2.3 million and the $1.2 million that are shown on this slide here are, is the full value of what was spent by members as well as the county on services that could go through Marathon Health. So we, we built this in as being cost neutral for the budget for 2027.

0:50:24But in our modeling, we do anticipate based on both low and moderate engagement levels that there will be some savings coming from the things listed on this screen. So just reduce cost of care. Well, and just to clarify on the $1.2 million, those are out-of-pocket costs that members spend spent for their care in 2025, which if they went through Marathon would be $0 for them to get in a Marathon clinic. So while the plan savings is— yeah, so that— I think that was the piece. MJ team, this is Courtney Hutchison. If I may chime in for a moment, I flipped to the appendix. I think there's some helpful exhibits in the appendix that can answer both of these questions. So what we're showing here on the screen is 2025 full year, and we're calling this direct primary care opportunity. So, as both Jamie and Kyle alluded, these are dollars that were incurred by a variety of, at a variety of different places that had Marathon been in place in 2025 could have gone there instead.

0:51:38So, the $2.3 million is what the county paid for those claims. The $1.2 million on the right is what employees and members paid out of pocket. Had those claims gone to Marathon, all of them, both of those numbers would have been zero. Now, that's not reality. Not every single claim that could go to Marathon is going to go to a Marathon clinic, and there are some fees to access the clinic which would offset those savings. So that is why it is being budgeted as a cost-neutral change, at least in year one. In reality, there is only upside. It could very much save the county money, but this $1.2 million immediately goes away. If a member chooses to access a Marathon facility, they pay zero. They pay zero on the high deductible plan, they pay zero on the hybrid PPO plan. So that savings to the employees is real and immediate. The savings to the county is also real and immediate and only goes up as more people use it. So I just wanted to connect the dots on those dollars. They are savings opportunities, not additional cost.

0:52:46There was also a question I wanted to address around communication. The other really great advantage is when we— if you think about your own enrollment guide that you look at during open enrollment, there's usually columns that say, you know, when you have this done, it costs this much. When you have this done, it costs this much. Imagine that same enrollment guide, except now you would see If you need to go to a sick visit at a doctor and you go to Marathon, it's zero. If you go to your current doctor, it's, you know, your deductible or your coinsurance or whatever. So, that is another great way to really highlight and incentivize the value of this plan. And then lastly, I was going to pull up the 14 locations. If anyone was curious, these are the locations across with the broader Denver Metro and Northern Colorado location area. To the cultural question that Commissioner Lochamín asked, I don't know, Jamie, if you know that off the top of your head. We could— we— I know they obviously, they do have Spanish language speaking, but Jamie, what else would you add to that question? Yeah, I don't know the specific numbers in terms of of Spanish-speaking providers. I do know they have some, and then within their virtual care system, they also have Spanish-speaking providers.

0:54:11Did that sufficiently address the questions? Yeah, thank you. Yep. Okay. Thank you. And so next, I think we were going to go into the plan design. Correct. Yes. So you see both, um, on the left, current plan design, just for reference. In the raspberry color in the middle is the BAB recommended plan design. Um, and then in the purple is the MJ recommended plan design. Uh, and they saw both of these options as was stated earlier. The recommended plan design is some small incremental changes to the deductible as well as the out-of-pocket in-network, and then some copay adjustments on the hybrid plan, along with some out-of-network adjustments to the deductible and out-of-pocket just to be in alignment with the in-network. Really big reason to make these changes is over time with the cost of care increasing, it's important to incrementally increase those deductibles, out-of-pockets, on occasions copays, so that employees are gradually taking on the same amount of costs as the county. In the MJ recommendation, we have a slightly larger increase to the out-of-pocket in addition to the increase to the deductible and then further increase to the out-of-network benefits, really to attempt to disincentivize out-of-network utilization and to align with some of the increases to deductible and out-of-pocket. And then the additional item that we're— we proposed in this plan design change is the

0:56:11elimination of out-of-network for cross-accumulation, which I have a slide on next, because current state, it is an inequitable benefit where it applies on the consumer choice plan but does not apply to the hybrid plan. So if there are no questions on, on plan design specifically, I don't want to pull it down too fast, we can move on to the next slide. I do want to talk a little bit more about, in addition to kind of plan design equity and not wanting to have out-of-network benefits kind of steer people to one plan or another, highlight some of the reasons that we thought it was important to eliminate the out-of-network plan design. So I'm going to kind of hit the items in that Raspberry table first, and I will talk about the exposure level associated with each as well as kind of the, the risk really. And out-of-network plan design changes really focus more on the risk to the plan as opposed to the actual dollars spent.

0:57:33So out-of-network, when individuals are using out-of-network providers, kind of eliminate the protection of contracted rates. So providers can bill whatever they would like in an out-of-network scenario. And in addition, you're paying a shared savings fee from Aetna. So those tend to add up quickly. So moderate exposure, there in terms of frequency and then moderate cost exposure as well. The next reason is kind of newer and something that we always are put— we're putting in front of all of our clients is a risk of independent dispute resolution, or what we call IDR. What that is, is when a provider is seen out of network and they they submit the claim to the insurer, ultimately the provider can lose out on some money. So they can file an independent dispute resolution, which essentially is their ask for more money. More often than not, we're seeing those IDRs result in additional costs that have to be paid by the employer. So while you are not seeing them terribly often, the county has not seen one yet.

0:58:51That the risk in terms of cost exposure there is fairly high. Um, this benefit— out-of-network in general, but in particular the cross-accumulation of benefits— also takes away from your contracted rates and any incentives that members have to use in-network providers. So they absolutely should have a choice. Um, the BAB did not vote to recommend this one. Uh, I think primarily because they believe that providers should have choice. This is not eliminating the choice, it is eliminating, um, the cross-accumulation, which means you're taking the dollars paid by members out-of-network and you're applying them to in-network. So members are meeting their deductibles as well as out-of-pockets sooner, and the county as a result is taking on more cost. And there are a decent number of individuals taking advantage of out-of-network benefits today, 270 on the hybrid plan. That is not a cross-accumulation issue, but the 357 individuals on the consumer choice ICE plan would be impacted if we were to move forward with removing that cross-accumulation, which is the recommendation of MJ.

1:00:34Not seeing any questions. We can keep going. Okay. Thank you, Jamie. And I think just to put a bow on this one, the The plan would still have out-of-network coverage. Members can still go out of network just like they do today. The only change is that they have to satisfy separate deductibles and separate out-of-pocket maximums, whereas today they get— they can kind of blend the two. Honestly, it's about equity between the plans more than anything else. There's a lot of risk and a lot of exposure that Jamie touched on, but it's really about, in our isolated MJ opinion, treating the same— treating members on both plans the same. But that's my takeaway. All right, one more final BAB recommendation before we move on to premiums, and this one's over to Andrea. Yes, thank you. This is Andrea Crone again from the MJ Companies. So, as I noted earlier, the MindCo utilization— so, again, to Commissioner Stoltzman's question earlier, really utilization, who's actually using the program and engaging in it.

1:01:38Using the app is, is far below what is needed for those programs to really have a meaningful impact for your employees. I will add really quickly, and I should have said this before, the BAB members did also seek feedback from each of their departments on MindCo, if they had used it, what their feedback was. And, and to your point exactly, Commissioner Stoltzman, there was feedback around, I've used it, but I was dissatisfied with the app, or the headset didn't work, or it was uncomfortable, or I didn't want another app. So there was some, some relevant feedback there. Um, the county does have alternative stress relief and tobacco cessation support that's already available through programs that you have in place. So, for example, through your employee assistance program with CareLink, um, your medical and pharmacy plans can help treat mental health and stress disorders as well as prescribe medications as needed. And then you also do have a wellness program that's already in place that that offer support for these specific types of services.

1:02:36So with that information in mind, both the BAB and MJ recommend terminating this program for 2027. This will result in about $110,000 per year in savings for the county. And really where that comes in is MindCo charges a per employee per month fee for every eligible employee, regardless of whether they are using the program. And so again, with such low utilization maybe around 8 or so people per year using each of these programs, but you're still paying for the full population to have access. And for your consideration, we have included some additional information about this recommendation in the appendix. Thank you. All right, Kyle. All right, Kyle Sullivan here to talk a little bit about what the employee premiums might look like. So as Andrea mentioned, we did have— the BAB did survey their members and the members they represented, and one of the things they came back with is they wanted to ensure that there's a balanced approach to managing costs. So not only looking at changing the benefit design, but also considering changes to the employee premium premiums that come out of their paychecks.

1:03:55During the BAB session, they recommended shifting an additional 1% of employee premium cost share to employees in a way— or in an effort to help manage and reduce the cost increase to the county. Both of the scenarios that we'll look at here will show a status quo scenario, and then we'll discuss the two proposed scenarios. So just to set the baseline, the status quo scenario based on our current cost share has the $36.9 million total broken into the county portion and the employee portion. So the employee portion is currently 13.3% of the total annual plan spend, and the county portion is 86.7%. If we look at what that cost shift looks like, like combined with the plan design savings in each scenario, the 14.3% with the BABB recommended scenario has the total costs that have been reduced by $600,000.

1:05:00So the $36.3 million split into 14.3% of the total covered by employees, that would be an increase of about $300,000 from an employee cost basis. With the additional savings and the additional $400,000 savings in the MJ recommended scenario, that cost increase is reduced by about $60,000 to employees, and the employee cost share again is the 14.3%. I want to note that these cost shares of either 13% or 14% are very competitive among municipalities and employers in general. And we'll note on the next slide what that actual dollar amount to people's paycheck, the change looks like. But I just wanted to comment that it's been important for us to ensure that we're aligning with benchmark and ensuring that the full benefit package, both from a plan design perspective and a payroll deduction perspective, is robust. Can we stay on this slide for just a minute? Commissioner Litschman, do you have any questions? I do. I just am getting one other piece of information before before I can ask mine. Thank you.

1:06:14I'm waiting for the slide that shows the breakdown of what that costs with the different employees. So, okay. Thank you for asking. Are you breaking this down further on the next slide, Kyle? Yeah. Yes. The next slide will show the monthly rate. So it will absolutely address or help address that. Let's see that, and I might have you go back to that last slide also. Sure. Perfect. So we want to start on the left here with our current plan design offering and our current payroll deduction. So on the top, just orienting, we have the Consumer Choice Plan. These are all monthly employee deductions based on the plan election and the coverage tier election. If we're looking at the middle column, this represents the change on a monthly basis based on each scenario. As I mentioned, a balanced approach with less plan design changes.

1:07:06There is an additional increase, or a slightly higher increase, to employee rates. On the Consumer Choice Plan, the monthly change is between $16 for employee only and $69 for family coverage. In total, we're still looking at a little bit over $350 per month for family coverage, which is extremely competitive, especially in the current healthcare market space and considering how much your plan design covers is very competitive. From a hybrid plan perspective, that increase is higher, so it's $22 for an employee per month in addition to our current amount and an additional $89 for family coverage. Still, we're our total family per employee per month rate would be less than $500 for your buy-up plan offering. Do you have a question at this point or do we want to talk? Yeah. No, I think I do. So if you could go back to the last slide, I think it's a little cleaner of a question on that slide.

1:08:15So on the— I see that you've tried And the BAB recommendation and your recommendation, you're trying to show a similar cost share between the county and the employee of the county. And so going back to the plan design that drives that, you're essentially trying to drive down that cost to the employees and county by increasing the out-of-pocket max and reducing the risk. Is that right, Kyle? For the total, yeah. So the total amount reduces due to that. And I honestly probably should have highlighted the county's portion here because that's one of the really key considerations. If we look at the county status quo, we're looking at $32.0 million. In the middle column with the recommended change in cost sharing and plan design, we're looking at $31.1 million. So a $900,000 difference. And then in the MJ recommendation, we're looking at the $30.8 million. So that's a piece I should have mentioned earlier. No, I see that. I'm really focused on the employee row, actually. And so it looks like you've tried to keep that 14.3 to 85. fixed while using the plan design to reduce the risk basically on your side. So the risk is essentially getting shifted to employees that may experience more sickness, like right in their out-of-pocket max, that's where it's made up for. Is that right? Correct. That's what's driving the

1:09:43change in the total. All right. So like as far as like who benefits and who burdens between the raspberry color and the purple color, like the employees that are experiencing more chronic illness or maybe hitting their out-of-pocket max are who are being burdened with the purple design? Correct. There would be— and then healthier employees are benefiting in the raspberry, or I guess healthier employees are benefiting in the purple. Yes, from a plan design perspective. One of the considerations discussed during the BAB was that there's this interplay between if the county is paying more in benefits, that that also might reduce the amount of compensation that could be passed on. And so that was one of the considerations in the purple is if we're able to mitigate cost there, that it might help ensure that employee increases are not burdened by additional increases from the benefit plan.

1:10:38I mean, but you're just positing that because we've not talked about that. So I don't have any other questions. Thank you. Thank you. Kyle, it's Courtney again. If I could just chime in, I really appreciate Commissioner Stoltzman's comments. One analogy I like to use is if you focus first on the total, that number gets smaller as we move into raspberry and into purple, so that the entire pie gets smaller when you change plan design because the dollars, you know, the dollars, the cost of the dollars go down. Obviously, the employees have to pay more at the time they use care. So that's decision point number 1, which was driven by Marathon and the plan design changes, obviously, we've been talking about. Step 2 is to then determine how does that pie get divided into 2 pieces, the piece the county pays for in premiums versus the piece the employee pays for in premiums. And that's driven by this cost share.

1:11:28So it's, you know, you'll notice this 1% shift. It's 13.3% today. The proposal is for the employees to pick up an additional point of the total. The total is smaller in these two scenarios, and you're absolutely right that it's a bit of a balance between, you know, if we've got this pie to split in half, you know, raspberry gets you a lower number through, gets you lower on plan design. Purple gets you even lower on plan design, but you're absolutely right that people who would feel that would be the people who use care the most, i.e., being the sicker or the folks that just use more care. And that was exactly the conversation during the BAB and all that is outlined on the readout in the back. So you articulated that perfectly. Thank you. Any other questions on the plan design?

1:12:22At this time, thank you. Thank you. So let's see, next topic. Any questions on the rates and the change to the employees either? Just in regards to the rates, for me, I think my questions are going to come later when we're talking about the actual figures and numbers. So I'm holding on to thinking about this one. Okay. Dental premiums. Dental premiums are very exciting this year. There are no changes to dental premiums as we're in a rate guarantee. So I'm pleased to present the current and 2027 dental premiums and employee deductions. Thank you. Vision premiums. Very similar to dental, one of my favorite subjects. We're in a great spot for having these rates locked in for another year. So no changes to vision premiums. Thank you. All right, this is Andrea Crone again. Just a quick renewal summary here for you. Really, this is highlighting when your programs are up for the next round of RFPs. Just wanted to highlight that we did complete RFPs this year for life, disability, FMLA, and leave administration earlier this year, so those have been completed.

1:13:48And the RFP panels of course voted to move those programs from Lincoln Financial over to Unum for life and disability, and then to bring the leave administration in-house with a software called PulpStream. We do have the stop-loss RFP coming up. That is something that we typically market every year just to ensure you're getting the most competitive rates. So that is upcoming. And then, of course, the virtual mental health and tobacco cessation through MindCo that we do recommend terminating that on December 31st, '26. And then after that, we do have some additional RFPs coming up next year, really high-level, just flexible spending accounts, COBRA administration, and identity theft. And then we're, we're good for a little while after that on the need for RFPs for these programs. Thank you. Before we go to the discussion on those topics, just are there any other topics commissioners have that weren't covered in the presentation or ready for discussion?

1:14:53For me, Commissioner Salzman, I'm really— I want to have a discussion with you around the recommendations and what I'm wanting to look at more specifically what happens if we don't make a change on the benefits. What does that mean to our members? So if this is the right time to talk about that, that's great. If it's later, that's fine too. That's great. We will— we can do that right now. I think that I wonder if MJ or Budget has any, you know, sometimes we see a slide that shows like the overall cost of like status quo, overall cost of the BAB recommendation, overall cost of the MJ recommendation. I wonder if we have something like that you could take us through. Yep. Let me go back to that. Thanks, Courtney. That was 23, I think. Oh, nope.

1:15:48Oh, boy. Trying to go backwards. This one. This is specific to medical because that's the only piece that's changing in cost. Everything else is staying the same. So, we're— if you do nothing, it's a 36.9% $1 million total county spend, which is a $2 million increase over where we anticipate you ending this year. And then if you do the BAB recommendation, it reduces that by— it reduces that by $600,000. If you lean towards the more encompassing plan design changes being recommended by us, that takes it a little bit close, a little bit further. And then the secondary recommendation after that is is how that cost is then shared with employees via their premiums, which was that 1% additional cost share that the BAB has recommended. Thank you. I think for me, I'm— what I'm trying to understand, and included in the recommendations of those different line items at the beginning of the presentation, first slides or so, but what I'm wanting to understand I would like to see a world for this next year that we're talking about in no increase to deductibles and no increase to out-of-pocket max. So I'm thinking I might be interested in some of the recommendations, but I'm trying to really look at how it might not impact employers. And I understand there's a—

1:17:20cost of us as the county. Courtney or Kyle, do you want to talk a little bit about which— that would— yep, if I may comment, that would be this number right here. This is if you change nothing, if you leave everything the same, all your plan designs, all your deductibles, all your coinsurance, etc. That would be— that's what we're referring to as status quo, for lack of a better word, and that would be the dollar amount that would then result in higher premiums to employees versus what we've shown here. Because as a reminder— well, actually, no, let me go back. Sorry. What page is the— what page are the premiums on, MJ? Team, help me since I'm sharing my screen. Sorry, I need to come off here. 29 and 30, Courtney. Okay. So here are your 2026 rates that employees are paying right now. If we don't change the plan design, these numbers would all go up by even more than what you see over here.

1:18:32We don't have a slide for that, but that just directionally So if it weren't— the total cost was going up higher, therefore the employee cost is— their plan design would stay the same, but their premiums would go up And it's— some of it hinges on that cost share piece that we talked about, that additional 1%. So if they were to keep the current cost share, it would be different than the two— the two impacts we're showing here have that higher, that 1% higher cost share. Or 10.3% currently. Yep. And for reference, the BAB did vote on that scenario, leaving the— and that was not the prevailing recommendation. Okay. So I hear that, and I'm looking at this, and to me, an $89 or an $83 or state $60,000 or $65,000 is a significant amount of money, just taking into account all of the other costs. What I'm looking for is if we didn't have that increase, what is that number?

1:19:45What's that cost? Like, it was a $4 million number. And then I also think maybe— so those are some of my questions, Commissioner Soltzman. And then we need to go the different line items that are being asked, plan design. Happy to look at that because I may help. May I clarify? So I believe what you're asking for are two things. One, leave the plan design exactly the same, and also two, leave premiums exactly the same as they are today in 2026. So essentially no increases at all to employees either in either bucket. Is that what I'm hearing, or did I misunderstand? I'm actually— I'm not looking at the plan design right now. So there is some of the plan design that I will be supportive of in the recommendation. So it might impact this piece, but what I'm trying to— what I would like to see is what would it cost the county to not have an increase to the employees' premiums?

1:20:45On premiums. Okay. I don't know that we have that modeled since that was not a scenario contemplated by BAB, unless Kyle or Paige, you know otherwise. We did not explore that scenario. The current employee contributions represent about $4.2 million. So that would be— from the status quo scenario, that would be an additional $700,000 shift from employees to the county. And then the other scenarios would follow similarly. So at $4.2 million in the middle scenario, the difference there is about $1 million. So the county cost would increase by $1 million. And that would be pretty close to that in the far right as well. To not have a change in the premium. Premiums for this next year. Correct. Okay, thank you. Thank you, Kyle. Thank you. The question I have that we just haven't covered yet before we get into the 5 decision points that we need to make today, um, is just really around GLP-1 coverage. I've had a number of employees from different departments talk about, you know, previously we were covering GLP-1s and it was really helping folks with cholesterol and weight loss and working, and many people now are having to pay $500 or more a month to continue that coverage since it's no longer covered and just wondered if there was discussion or if there are approaches that we could take looking at next

1:22:18year in our conversation to try to get some of that coverage back for folks. I think the state bulk purchased two particular GLP-1 products and I think some other employers are taking some innovative approaches. So I wonder if there's any discussion or if there's anything we could look at around that space. Jamie, may I ask you to chime in on the discussion with, with BAB, if any, regarding GLP-1s? Yeah, so we have not had any discussion with BAB regarding bringing back GLP-1 coverage. We did have some general conversations around state of the market and what is happening in the GLP-1 space. There are some non-plan-sponsored options that are available, which include direct-to-consumer programs that offer the drugs at a lower cost than if they were to just pay a cash price at the pharmacy counter.

1:23:23And that typically runs $400 or less. Depending on the dosing and which drug they're picking up, if it's in pill form or injectable. But we did not explore anything specifically for this year, knowing that we just eliminated the coverage in 2020— for 1/1/2026. Okay. I do think that's something that's important to talk about at BAB in 2027 in the discussion, just understanding where people are and getting a pulse on employee feedback on that. Um, just because that's something that consistently comes up for me when I talk to employees in different departments. I also have a question on the same topic, if that is something, you know, when you're working on your contracts and sales pitches and things with Marathon Health, if that's something that they would consider offering at a rate, like at a fee, um, like if that is an expansion of services that they'd be interested in providing. I think that may make it more likely that people would use the service. Yeah, they absolutely have. Go ahead, Courtney, I'll let you speak to it.

1:24:27I think you're a little more familiar with the specific program. Yes, I was going to say I've made a note to bring up, to request that the BAP speak about GLP-1 coverage again next year. I won't go to it in the interest of time, but in the appendix of this presentation, there is some data on the impact of that change and, you know, the amount of money that the county is saving as a result of that change. And we did review all that information with the BAB as well, and there was not a recommendation to bring the coverage back. So, but we will, we will add that to the list. You are, your question is a fantastic one. I know we don't have anyone from Marathon on the line today, but I do know that they are exploring ways in which they can add dispensing of certain GLP-1s for certain reasons. At their clinics as well.

1:25:19That's an active business strategy of Marathon, and I agree with you wholeheartedly that if they're able to do that, it would certainly increase foot traffic into Marathon clinics if that were the only place to obtain your medication for GLP-1s. Okay, if they want to talk to a county commissioner, I'm happy to meet with them. I'm sure they would love that. We will pass that along. Alright. Okay, so I think that brings us to the 5 decision points that we need to talk through this afternoon in discussion. You've formatted them a little bit different here than they are in our packet. Okay, happy to pull the screen down if you'd rather. I think it gets us to the same place. I just wonder if Commissioner Lauchman, if your notes are in line with what was written in the text of the packet, or if you want to go through them in the order they are here. It's slightly different.

1:26:10I'm really okay either way. Okay. On this slide is totally fine. It makes— so the difference I'll just note that I'm noting, and maybe I'm reading it wrong, in the way that it was designed in the text of the packet, there are like two differences where MJ has a different recommendation than BAB, and I think that the way they've been presented here, you've combined both of those into the fifth point. Is that right? Right? I apologize. I don't have the packet that you're looking at in front of us, but I think what you're maybe alluding to is the additional plan design changes. Again, it would be either 2 or 5. 5 includes those additional changes Jamie went through and the out-of-network cross-accumulation item. Right. So, like, those are just separated slightly differently. Oh, okay. My apologies. I didn't realize it was presented that way. Presented to you that way. Okay, so we'll start with Marathon Health. Commissioner Lutchman, how do you feel about the BAB recommendation on Marathon Health?

1:27:10Do you want to tell me, if you don't mind, which page in the packet that you're looking at the decision points? Sure. I just flipped to there. Sorry, I'm switching back. So the decision points are actually on I'm on one screen, so I'm not, but I've got it up in front of me. Great. Well, maybe I've got the whole packet, so that's— just a second. I have the 60-page packet up, and it's page 2 is what I have with it on there. All right, I won't worry about of that piece. Um, let's see here. On number 1, introducing the marathon pill. Yeah, I'm, I'm in support of it. I, I had a lot of questions. I have some concerns that I think are just kind of the what-ifs in the world of healthcare and if we get people really using this particular addition to what's offered and in those 14 start to pull back the same way the brick and mortar has in the healthcare space.

1:28:23I've got those types of concerns. And just seems like there's— it could create another alternative. I had a similar question on the JLP as well, Commissioner Sullivan, because I thought that was something that was going to be continued. I mean, again, what these two events, you know, additional options inside the decision was turned back from policy. So I'm glad you brought that back up. And it seems like that might be an advocacy piece. And there may be some other things that had to remove with the changes that I haven't thought about, but I think that makes sense to do some advocacy and hopefully with that program. What are you thinking on number 1? I think that it is a good thing to do with how it's described this year, but similar to you, like I do concerns of the what-ifs in the future of like, well, it makes a ton of sense as it is now, but is this really just a way to hook people in and then it'll be a cost increase or it will, you know, compare differently in the future. So I do think we'll have to continue to evaluate it, but as it is presented and funded in the, in this decision, I think it's a positive choice for employees at no cost that can

1:29:33reduce their costs and reduce county costs and give another option. So for what it is now, I think it's great and we'll have to just keep a close eye on the future for like all the reasons you described. Described. Okay, so the second thing we have to talk about is the medical plan design changes. So this is where the BAB was recommending changing the deductibles and out-of-pockets on both medical plans, and they were trying to— it looked like essentially reduce the out-of-pocket max compared to the MJ Team recommendation on that one. And just MJ Team, if you're listening, we're going to talk about the cross-accumulation separately. So we're just talking about the— on this particular discussion that we're having, we're just talking about the changing the deductibles and out-of-pocket maximums on both plans. And I don't know for the discussion if it's helpful to put that slide back up or not, or if we can just discuss it. I think that we might be trying to find it on the packet.

1:30:33This one here, yeah. Thank you. So this is— thank you. For me, what I'm worried about right now is the addition of cost period. So when I'm looking at this, it seems like, as an example, the current hybrid, just on that first line, from $1,500 $1,500 to $1,750 or $3,000 to $3,500, that is just, that's a significant amount. So I would really like us to figure out what we might be able to do to reduce, you know, the premium costs, whether it's the monthly premium or the visit premium or the collective deductible. It's just a lot of money for employees. I think that's why we're seeing the difference in the BAB recommendation versus the MJ recommendation. I think MJ is trying to present something that contains the cost overall and the risk overall between the employees and the county. But the BAB, I think, tried to land at, you know, we see these costs going up over time, we know they're going to increase year on year, and if we can reduce that burden on the employees, that has a significant benefit.

1:31:52And then I think that when I look at what the BAB's looking at, it's just distributing it it, it's talking about healthcare is always rotten because it's like, well, obviously no one wants to get sick, but if you get sick, you hope that collectively society is going to like pitch in and we're gonna help cover the costs together. So I, I just, I see the BAB recommendation. Um, and I think I would lean toward what the BAB is recommend— recommending on this over MJ because I think it's trying to get at addressing what you're trying to address, but recognizing that the costs are accelerating so much and in this medical space? I think when I look at this, I'm reading this as something in the chat here. Is that something you want to share, Courtney? Well, I just— I— Sure, go ahead, Courtney.

1:32:46So I didn't know if that data point would be helpful or if it was appropriate for us to chime in that the virtual setting is difficult. I apologize, but just, wanted to make sure that the data point was shared that the out-of-pocket maximum is generally not applicable to most members. It is very— it is reached by only a subset of the population. Sure. That was all. Thank you. I think what I'd like to just explore a little bit is I appreciate Fab's work and, of course, MJ's work as well. And if there's a way for us to decrease that cost even to the amount that the BAF is recommended, I think you're right that they're acknowledging that there is most likely going to be a change. But I think the BAF ability as well to look at what would that cost be and what could we consider.

1:33:41And I know that probably makes it complicated from, you know, OFM sitting there trying to run numbers. But I, if there's interest, Commissioner Salzman, I would like us to see if we could add something in there to reduce the third item. Sorry, will you just repeat reduce which item? The burden of the, just the, the actual cost to employees. And so if that's premium, if that's the deductible, if that's wherever that is, I think I would like to see us add something into both of those. Um, so I don't think we have all of the information we would need to be able to do that today, because I think the piece that's missing is like that essentially creates what I was hearing from Kyle is an additional million dollars, um, in funding gap from the county side per year. So like, as far as our structural debt goes, like that actually makes us have to find another million dollars And so I think we would need OFM to do some additional work on that. So I guess the question I have for— I would normally send it toward Emily Cooper, so I'm sort of wondering who's with us in the room that can help us, but about the necessity of having this decision made today. Is there someone from

1:34:57HR on this call? Hi, Ashley. It's Stephanie Hyatt. Yes, I can work with the MJ team and finance, OFM, and they can crunch the numbers to see what that would look like. Do we have time for that, Stephanie? That's what— that's the question that I was wondering is like, is this like, do we need to have this locked in? Is it time sensitive for today, or do we have time to get that info back? I do think we have a little bit of time. If, you know, if that's something that you want to see before you're comfortable making a decision, I don't think that the BAB is planning to be meeting again. So as long as you're okay with just getting those numbers and making the decision with, you know, what OFM provides and the MJ team with kind of revising and adding to, Yeah, so I think what we need is sort of a fourth, basically a fourth option presented here that would show the in-out-of-pocket maxes and the deductibles staying the same essentially, right, Commissioner Lochaman, and shifting that percentage. So instead of the, I forget what the actual presents were, but it was something like 84% to the county, shifting that county share and then showing what that does. Does for the recurring expenditure from OFM side. Does that make sense, Kyle, what we're

1:36:37asking to look at? Yeah, I just wanted— this is Kyle Sullivan— I just wanted to confirm. So we're talking about the same, so basically it would take our status quo scenario that we showed, but we would be combining that with the current 2026 employee cost share, and then what does that mean to the county from absorbing those additional costs. Yeah, the current employee payment, not cost share, because the share would shift to the county, right? Yeah, so employees would pay the same in payroll deductions and have as close to possible the current plan design. And that's the reason I mentioned that is there's a bullet at the bottom of this page that the IRS requires a $50 and $100 increase to the deductible to remain compliant. So there will be some change, but that's as close to no changes as possible.

1:37:32So yes, that is the design we're hoping to see more detail on. Okay. Yeah, that— thank you for that, everyone. I just want to add a response for— I'm sorry, I think it was Stephanie, maybe. Yes. Thank you. I would feel comfortable with out because I feel like this would be more favorable. So just, just in regards to the— just say, I think that would be okay. Want to check in on Commissioner Sullivan. If it was going the other direction, maybe I would want to have conversation, additional meetings. I actually— sorry, could you just say that again? I, I wasn't understanding. Oh yeah, um, I, I thought I heard a question from Stephanie or a comment about if the board would feel comfortable, um, seeing changes without having the— a board member present. And for me, what I'm asking would be more favorable for staff, and so it doesn't concern me about not having an additional meeting. Is that clear? Yes. Yeah, thank you for clarifying. Yeah, I'm The part of it that would be very nice to have Bob weigh in on, of course, is like what the effect of the structural deficit is. I think that was in some of the notes of the conversation, but I think they have contributed quite a lot of feedback. So seeing

1:38:58that other scenario, I think builds on the feedback we've gotten, and then we can compare the 4 scenarios that we have and have that discussion. That's great. Thanks. All right. The next topic is the medical premium contribution changes. Is. And I don't know if you all want to change slides back again, but I think the medical premium contribution changes, it looked like MJ and Bab were in alignment on. But do we need to put a pause in this discussion if we're waiting for that other information? Yes. Okay. So we'll put a pause on that. And then the next discussion is termination of the MindCo benefits. Benefit, and it looked like Bab and MJ were in agreement that we would recommend terminating the MindCo benefit and save the $110,000 a year. Any discussion on that one? I'm supportive of those recommendations and having some of that additional information just to understand the context because I had heard something different as well last year. So it's helpful again for evaluation, just review.

1:40:10Great. And then the last topic is the cross-accumulation on the consumer choice plan. Any discussion on that? If I can just ask Commissioner Solzman, I'm guessing you were fine with my recommendation. I just didn't hear— Oh, sorry. Yes, I support also. Sorry about that. Support the plan. The last one is this cross-accumulation of the consumer choice plan. And so Bab was recommending that we go ahead and leave it like it is designed now where the consumer choice plan is a little bit different out of network than the other plan. And MJ was recommending making them both the same. That— this one concerned me when I see the amount of people who will be impacted. Me too. And so I just feel like there's so much changes going on with so many different processes, certainly depending on where we're going in regards to a change in premiums for people. I would rather not make that change at this point. All right.

1:41:09So I think what we would be doing today is it sounds like we agree to direct staff to adopt the BABB recommendation on Marathon Health, adopt the BABB recommendation on the MindCo benefit, and adopt the BABB recommendation on the cost accumulation, which is to not make a change in that space. So those would be the 3 BAB changes that we're giving direction to move forward with today. And then we're going to come back at a future meeting and continue to discuss the medical plan design changes and the medical premium contribution changes. Is that right? Well, help me if the first 3 part— first 3 pieces, Yes, the one that you just said about coming back for plan design. I guess I was interpreting all of these changes as plan design, so I just want to make sure that the group knows what we're asking. What I read in the packet is plan design. It says BABB recommends changing the deductibles and out-of-pocket maximums on both medical plans and some small changes to prescription copay tiers on the hybrid plan. These changes will help lower the 16% increase increase in premiums to 14.6, and then the MJ team recommended further bringing it down to 13.4%. That was the thing that was described as medical plan design changes, and that's what I think we have to come

1:42:31back and talk more about with the additional scenario that you've described that we'll look at. And then in concert with that, they called medical premium contribution changes in the packet. The BABB recommended shifting 1% of the premium contribution split from the county employees, making it an 85.7% county paid and 14.3% employee paid. And in that one, Bab and MJ had agreed, but I think we can't decide on that without the additional information that you had put together too. So that's what I'm talking about when I talk about the coming back to talk about medical plan design changes and medical premium contribution changes. I think that's a great clarifier. Okay, and so we can go ahead and move forward with direction to staff on the Bab recommendation on those other 3 items, and we'll come back at a future meeting on those remaining 2. I'll turn back over to Stephanie to see if there was anything else she needs us to answer today.

1:43:27I don't have anything else. I'll work with everyone involved, and we'll get that future meeting scheduled. Excellent. Thank you all very much for being here today, and just another thanks from the board, Kelly and BAB members, for all the time and energy you've put into it and helping us understand how this will affect each of your departments. It is a tremendous amount of time and work you put in talking to everybody, going to all the meetings, understanding all the actuarial data, and it is really helpful. So thank you very much. And with that, we'll be adjourned for the day. Thank you all. Thank you. Thank you. Bye-bye. Thank you,