Reliable and Sustainable Solutions
Providing Better Care, Lower Costs, and a Healthier Business
Take Back Control of Your Benefit Costs
Better Healthcare
Lower Employee Expenses
Better Healthcare
A quality health plan helps businesses recruit and retain top talent. It reduces absenteeism, and helps boost productivity. We will help to create a plan to fit the needs of your business.
Sustainable Costs
Lower Employee Expenses
Better Healthcare
Health insurance costs are out of control, witnessing double-digit annual increases, and comprising the number-one or -two line item cost in most small to medium-sized businesses. It’s unsustainable. We are here to help you gain control.
Lower Employee Expenses
Lower Employee Expenses
Lower Employee Expenses
High medical costs—even for the insured—are one of the biggest causes of personal bankruptcy. Worse, they keep employees from seeking care, staying healthy and working at their best, which affects company performance.
How It Works
We help solve many of the historical complaints of small employers purchasing fully insured coverage. With fully insured products, employers have low levels of transparency and flexibility, and any profits created when claims are low are kept by the insurance company.
Level-funding works differently. As a self-funding arrangement, claims are paid directly from your claims account and unused amounts are eligible to be refunded to you. Stop loss insurance is included in the package to help protect you from large claims and keep cash flow predictable. If claims exceed your claims account funding at any point in the year, stop loss will advance funds into your account.
Regardless of the level or timing of claims, your monthly bill will remain one level payment that does not change during the year. The primary cash flow risk is whether or not you will get a refund.
Your Monthly Invoice will Include Three Components
Claims Account Funding
Claims Account Funding
Claims Account Funding
It is your money and these amounts pre-fund your maximum claims exposure for the year in monthly 1/12 increments. At the end of the year, depending on the option you select, you could receive 50-100% of the remaining unused funds after the claims runout period.
Stop Loss Premiums
Claims Account Funding
Claims Account Funding
Premiums are paid to the stop loss carrier in exchange for protection from claims above expected and provide the coverage that puts the “level” in level-funding.
Administrative Fees
Claims Account Funding
Administrative Fees
These amounts pay for the ongoing administration of your plan, including customer service, claims adjudication, reporting, network access, and broker fees.
Flexible Network Options
5 Types of Network Plans: Varying by Level of Savings, Network Breadth, & How the Provider is Paid.
Preferred Provider Organization (PPO) - Least Amount of Savings
- The traditional option that most health insurance carriers offer
- Broad National Networks
- Out-of-Network providers are covered, but at higher levels of cost-sharing (higher deductibles, coinsurance, out-of-pocket costs that the member is responsible for)
Exclusive Provider Organization (EPO) - More Savings
- Similar to PPO plans, only members cannot go out-of-network
- Broad National Networks
- Out-of-network providers are not covered, except in certain situations outside of the member’s control
- Some savings vs PPO
High Performance Network (HPN) - Great Savings
- Local networks that are narrower and focused around 1-2 hospital systems in a given geographic area
- Out-of-network providers are covered as well, but at higher levels of cost-sharing (higher deductibles, coinsurance, out-of-pocket costs that the member is responsible for)
- Significant savings vs PPO
Reference Based Pricing (RBP) / PPO Hybrid - Greater Savings
- Hybrid option, blending RBP and PPO approaches
- Reference-based pricing for facilities to drive savings, with a broad national network for higher frequency claims from physician and ancillary providers
- Savings in between PPO and RBP
Reference Based Pricing (RBP) - Greatest Savings
- Innovative approach in the market that reimburses providers at a multiple above the levels Medicare reimburses for services
- No provider networks are involved, other than for transplants and pharmacy benefits, and members can see any provider
- Strongest savings vs PPO
Customer Experience with Reference Based Pricing
Reference-based pricing plans can create significant savings for employers and members vs PPO due to how the plan payments work. On an RBP plan, providers are reimbursed at a multiple above the levels Medicare reimburses for services. These multiples are 150% for Inpatient Services and 130% for Outpatient Services and while higher than Medicare, they are often lower than traditional commercial network payment levels. As these plans do operate differently from traditional PPO plans, we will walk members step by step throughout the healthcare journey.
Review educational materials – The same standard items are provided to groups with PPO plans, such as the Summary Plan Description (SPD) , Summary of Benefits & Coverage (SBC), and an overview of online management tools. Members will also receive RBP specific materials to help them understand how to use their plan, such as an introduction to their Advocacy team and online shopping tools.
Shop for services – Members can seek out services from any provider on an RBP plan, with the option of relying on the assistance of our online shopping tools and/or our Advocacy team to locate high quality providers.
Payment of claims – Providers are reimbursed at either 150% or 130% of Medicare levels, providing a fair margin for any particular claim, but typically at lower margins than a PPO contract. The RBP payment can create savings for both the employer and the employee. See the chart below for an example for an Inpatient claim.
Post-payment questions – Providers may have questions on how the plan works or how the
payment amount was derived. Occasionally, providers may also attempt to balance bill the
member for the remaining amount of billed charges above and beyond what the plan paid. This is
when the member should engage the Advocacy team who will take over the interaction with the
provider. Members are not responsible for balance bills related to plan payment levels, nor do they
have to handle any explanations or negotiations with providers.
Example for a hypothetical $40,000 billed charge inpatient hospital stay where provider bills at 400% of Medicare, the PPO discount is 50%, and the member has a $2,000 Deductible, 80% Coinsurance, and $8,000 Out-of-Pocket (OOP) max.
Within outpatient services, durable medical equipment, infusion, dialysis, and ambulance are all reimbursed at 100% of Medicare.