Claims and Eligibility Administration – This function is provided by a Third Party Administrator (TPA) who maintains your enrollment census data, handles the daily claims processing, interfaces the various components of the plan into a centralized contact point, coordinates billing and plan funding banking activity in addition to many of the daily administrative activities.
Billing Administration and Plan Funding – The majority of this function is handled by the TPA. Once a month you will receive a fixed cost bill that includes premiums for stop-loss coverage and fees for any administrative functions. These costs reflect the census as of the billing date. Any subsequent changes are reflected on the next months billing. Periodically you will also receive a check register for review and approval that reflects claims processed. The frequencies of these registers are at your discretion, although we recommend no less frequent than every two weeks. Upon approval, the check register amount is electronically transferred through a zero based checking account and claim checks are released.
COBRA and HIPPA Administration – We will provide all of your COBRA and HIPPA administration needs at no additional cost. All we need from you is timely notification of newly eligible and terminated employees. These administrative functions include Initial COBRA rights notification, qualifying events notification, COBRA participant billing and premium collection, and HIPPA certification notices.
Provider Networks – We will utilize an established national network of doctors, hospitals and other health care providers as your “In-Network” providers. There is an access fee to use third party networks that appear in your fixed cost billing. We may utilize more than one network dependent on your locations and specific needs. There are a couple of typical ways that more than one network can be utilized:In some cases you may have a location where a different network would work better than the primary network being utilized by the majority of your employees. In this situation we can carve out the particular location and utilize a different network. For this location the rest of the program would be the same, just the network of providers would be different.
In other cases a regional network may work better than a national network for a particular location. In this situation we can utilize the regional network for services in that region and wrap a national network around it so employees can still utilize “In-Network” providers while traveling.
Stop-Loss Coverage – The purpose of Stop-Loss coverage is to limit the employers liability in a given plan year and allow you to set a maximum budget level. Stop-Loss coverage is shopped by Horizons Research every year and is purchased through insurance carriers. By shopping this coverage every year we can keep the pricing competitive. Since this contract is back-up coverage to protect the employer’s liability, we can change carriers every year if necessary without any impact on the employees.
There is a monthly premium for Stop-Loss coverage that appears on your monthly fixed cost billing. Stop-Loss coverage comes in two forms, specific and aggregate:
Specific Stop-Loss – This type of coverage protects the employer from catastrophic claims per individual participant. The limit to the employer’s liability per individual participant is the specific deductible level. This specific deductible level is set with a balance of risk/reward to the employer based on your experience, plan size, plan benefits and risk tolerance. Further, this deductible level can be changed each year, with your approval, based on experience and pricing.
Aggregate Stop-Loss – This type of coverage protects the employer from catastrophic claims from the group as a whole. The limit to the employer’s liability for the whole group is the aggregate deductible level. This aggregate deductible level is set based on your experience, plan size, plan benefits and specific deductible level. The annual deductible level is established by monthly aggregate factors. Each month the aggregate factors are multiplied by the actual participating census. The sum of these factors for all plan months is the employer’s maximum claims liability for that plan year. In addition to protecting the employer’s liability, the aggregate deductible level is also useful in establishing a budget. If you add the aggregate deductible level to the annual fixed costs, you get the plan’s maximum annual cost. The aggregate deductible level is also helpful in estimating the expected cost for the year.
Case Management and Utilization Review – The primary functions of Case Management and Utilization Review is to assure that procedures being utilized by plan participants are appropriate and as an advocate for the patient to navigate the complexities that usually accompany a medical procedure. The front line of these functions is Pre-Certification, which is required notification of the more expensive and complex medical procedures. This allows the plan to review the medical necessity of the procedure, the appropriateness of the treatment plan and gives the plan early notification of medical conditions that can benefit from plan intervention. This Pre-Certification is usually required prior to services being rendered for planned procedures and within a reasonable time for medical emergencies.
Disease and Wellness Management – Disease and Wellness Management are programs within the plan that are customized to fit the type of benefit desired by the employer and based on the needs of these services as identified by your plan’s experience. The more defined the experience the more we can fine tune these functions to address particular concerns. We prefer a case management model for Disease Management as this allows a trained medical professional’s supervision of the individual participants monitoring and treatment. Where there are many conditions that can be managed by this program, the typical conditions addressed by Disease Management are:
- CHF – Congestive Heart Failure
- CAD – Coronary Artery Disease
- GERD – Gastroesophagial Reflux Disease
- High Cholesterol
Wellness Management is custom designed based on the employer’s desires and budget. There are many wellness issues that can be addressed in different ways. Some of the more common issues are smoking cessation, weight management.
Pharmacy Benefit Management – The prescription drug benefit within your plan will be controlled by a Pharmacy Benefit Manager (PBM). This outsourced vendor provides many functions. Through their extensive national network of pharmacy providers it allows your participants to utilize virtually any pharmacy in the country by just presenting their medical enrollment card. When your participant provides their card at the pharmacy, the pharmacist can obtain information about your plan design through the PBM’s system so they can charge the participant the proper amount when they pick up their prescription.
Beyond accessibility to pharmacies, a PBM monitors prescription drug trends, provides research on trends and plan design and provides a buying power with the pharmaceutical companies that allow your plan the best pricing for prescription drugs and supplies. Most of the pharmaceutical companies provide rebates at the end of each quarter based on the volume of drugs purchased. Your PBM contract can be designed so that you receive these rebates or you can forfeit the rebates in exchange for greater drug discounts up front. We will monitor your plans utilization and advise you on which contract makes more sense for you.
Reporting – There are hundreds of report available to you regarding your plans performance, trends, benchmarking and looking for areas of concern. We have some recommended standard reports that are supplied at a frequency of your choosing. We can also customize reports based on the type of information you need. We will work with you to determine what information is needed and the frequency of those reports. There is no additional charge for any reporting.
Specialty Programs – There are many specialty programs that can be utilized dependant on the risks and problems areas that are targeted within your plan. We will monitor your plan on a continual basis and look for areas of concern, areas of potential cost containment and areas for improved quality.
One example of these specialty programs is our Specialty Drug Program. This is administered by an outside vendor set up to work exclusively with any of your participants that are taking self-injectibles (other than insulin) or other expensive drug regimes. By assigning a Specialty Case Manager to the participant they can monitor the participants to make sure they are following the proper treatment plan, assist the participant in ordering their supplies and provide the drugs and supplies at the lowest possible price.