Self Insured Plans
(Sample)
The following benefit design for a multi-state employer,
with 1000 covered employees, was implemented, with a large brokerage, in 1999 AND
continues today - with modifications over the last 5 years.
During this time the employer experienced a total savings
of $3.2 million that was saved from what was expected to
be spent on benefit costs.
The designs take into consideration a Self Insured Plan
with Specific and Aggregate Insurance Protection - using
a Preferred Provider Network (PPO) and also offering an
Indemnity Self Insured Plan (for those employees whom work
and live in areas not accessible to networks) with the same
Specific and Aggregate Insurance Protection. With this approach the employer has saved an average of 55% of billed charges which has been a great advantage to the employer.
| Doctor Visits |
$25 CoPay |
60% - R&C |
80% - R&C |
| Hospital |
80% |
60% - R&C |
80% - R&C |
| Surgery |
80% |
60% - R&C |
80% - R&C |
| Urgent Care
Fac |
80% after $30 CoPay |
R&C |
R&C |
| Outpatient
Hosp Exp |
80% |
60% - R&C |
80% - R&C |
| Diagnostics |
80% |
60% - R&C |
80% - R&C |
| Second Opinions |
100% |
100% |
100% |
| Nursing
Facility |
80% |
60% - R&C |
80% - R&C |
| Home Health
Care |
80% |
60% - R&C |
80% - R&C |
| Well Care
Benefits - Age Schedule |
100% up to $400 PP/PY |
60% - R&C |
80% - R&C |
| Mental Health |
80% |
60% - R&C |
80% - R&C |
| Alcohol,
Drug Abuse |
80% |
60% - R&C |
80% - R&C |
| Hospice
Services |
80% |
60% - R&C |
80% - R&C |
| Physical
Therapy |
80% |
60% - R&C |
80% - R&C |
| RX - PBM
- |
Retail |
Brand - Formulary - Tiered - 30 Day |
Generic - Formulary - Tiered - 30
Day |
| Maintenance
Scripts required - Mail Order |
Mail Order - |
Brand - Formulary - Tiered - 90 Day |
Generic - Formulary - Tiered - 90
Day |
The Third Party Administrator (TPA) is critical to the
"service" end of satisfaction for the employer
and employee and to administering the Plan. The employer
must make sure that the proper disclosures are in place
in all aspects of services provided by the TPA.
The Network Contracts are usually a necessity for fixing
a price to a negotiated service but employers whom expect
that the Networks are going to control quality and volume
- need to have complete disclosure in this regard.
Reinsurance carriers and their Master General Underwriter
- that some of them work through - need to be checked for
appropriate servicing, reimbursement access and possibility
difficulty in respect to specific and aggregate claims and
other areas of audit potential.
There are a number of other optional benefits such as Life,
Long Term Care, Critical Care Illness and so forth that
can be tied too or separately offered along with the health
benefits program of the employer. Niche Benefits integrates
these benefit offerings along side of the health benefit
offerings. In addition, special executive programs are developed
and are complimentary to the regular programs.
Brokers/Clients have been contacting Niche Benefits by using the following email address: sales@nichebenefits.com or calling the 888-428-8554- for further information.
|
