Carriers today are continually creating new plans in an attempt to reduce cost. Below you will find some of the more popular options currently being sold in today’s market. Please keep in mind that the below descriptions are just summaries. If you have questions please don’t hesitate to contact us!
Exclusive Provider Organizations (EPO) are networks of medical care providers which consist of Primary Care Providers (PCPs), Specialists, Hospitals and Ancillary Providers. Coverage is limited to these In-Network providers except in a true emergency. These plans are typically offered as either gated or non-gated.
EPO plans are typically the most cost friendly.
Point-of-Service (POS) plans offer both in and out-of network coverage. Like an EPO, the out-of-pocket cost while using an in-network provider will be much lower than using an out-of-network provider as all services and providers have negotiated fees.
Out-of-network services are typically reimbursed at a specific coinsurance level (typically 70% to 80% or 150% Medicare) after satisfying a deductible. Maximum allowable charges for out-of-network services are limited to a specific percentile of “reasonable & customary” charges or as a percentage of Medicare allowable charges.
Preferred Provider Organization (PPO) PPO plans are by far the most flexible option. You don’t need a primary care physician. You can go to any health care professional you want without a referral—inside or outside of your network.
Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you’ll have higher out-of-pocket costs, and not all services may be covered.
Health Saving Account (HSA) or High Deductible or Consumer Driven Healthcare plan. These plans have a “high deductible” that members must satisfy before the insurance coverage begins. Services like office visits, prescriptions, hospitalizations all initially accumulate towards the plans deductible. Once the deductible has been met, these plans then behaves like traditional medical programs. It is important to note that preventive care is covered at 100% immediately.
Accompanying the CDH plan is a Health Savings Account (HSA). The HSA is the employee’s personal account. Any funds in the account whether they are deposited by the employee or employer always belong to the employee even if they leave the company. The employee will use these funds to pay for any out-of-pocket expenses relating to the CDH.
CDH plans are not for everyone and require proper planning, and implementation. Employee education is crucial when setting up these type of plans. Fortunately, that’s what we are here for!
Group Medical Trends
Self-Insurance Options for Employers:
Because self-funding allows group plans to avoid many of the headaches associated with Health Care Reform, insurance companies have or are now beginning to introduce self-funded plans.
Also called Fixed-funding or Level-funding, these products have all the components of self-funding bundled together to create a turn-key solution for small and large employers. These plans typically include set monthly costs to protect against swings in claim costs, and should state clearly what your maximum costs could be. This innovative products act and feel like a fully-insured plan, but allow you the opportunity to save money when your claims run well, and avoid many of the costly Health Care Reform requirements.
One of the biggest challenges we face when determining whether this type of plan is right for you is the method in which these plans are written. Unlike the fully insured guaranteed issued plans many companies have become accustomed to, Level-Funded plans rely on your company’s employees completing medical questionnaires that once underwritten determine if your group meets the carrier’s requirements. We have a solution that makes this process painless to the employer!
PF Compass will help you:
- Determine if self-funding makes sense for you
- Choose the appropriate components of the plan
- Fully understand all risks
- Understand the carrier’s underwriting philosophy
A private exchange is an online store or marketplace where employers purchase benefits using funding contributed by the employers. Employers set an amount of money for their employees’ benefits and employees choose the benefits that make sense for their unique needs. Transparent pricing lets employees see the true cost of benefits and the value of their employer’s contribution to their financial well being.
What are the advantages to a private exchange?
- Gain cost control and predictability
- Streamline administrative tasks
- Get out of the benefits business
- Enhance employee benefits experience
- Gain control over benefits costs
- Find the plans that best fit their unique needs
- Understand and appreciate the value of their benefits
- Become better health care consumers
Multiple Employer Welfare Arrangements (MEWA):
MEWA (Multiple Employer Welfare Arrangement) is a self-insured health plan owned and managed by the Trust and its member employers. MEWA plans are trust designed specifically for small and mid-sized Employers. MEWA’s follow standard industry underwriting guidelines, establishes their own reserves and obtains stop-loss coverage from major reinsurers, just like the commercial insurers.
Why Choose The MEWA Health Plan?
This is a Health Plan owned by its member employers.
All profits go back into the Plan for the benefit of the participating members of the plan.
Excess surpluses can be used to increase reserves, provide refunds to groups, offset future increases or increase Benefits.
Professional Employer Organization (PEO):
A professional employer organization (PEO) is a firm that provides a service under which an employer can outsource employee management tasks, such as employee benefits, payroll and workers’ compensation, recruiting, risk/safety management, and training and development. The PEO does this by hiring a client company’s employees, thus becoming their employer of record for tax purposes and insurance purposes. This practice is known as joint employment or co-employment.