We have sat at every seat at the table. Source of the attached - - PowerPoint PPT Presentation
Self Funding Basics and Fully Insured vs. ASO Bundled Self Funded vs. Unbundled Self Funded Pros and Cons Mike Edwards: President MATRIX Group Benefits L.L.C. We have sat at every seat at the table. Source of the attached MATRIX Team
Self Funding Basics and Fully Insured vs. ASO Bundled Self Funded vs. Unbundled Self Funded Pros and Cons Mike Edwards: President MATRIX Group Benefits L.L.C.
“We have sat at every seat at the table.”
Source of the attached MATRIX Team Experience: Plan Sponsor, Independent Administrator, S.L. Carrier Executive, Hospital V.P., Network Builders
1. Nature of Business (SIC Code). 2. City, State, Zip (Multiple Zip Codes). 3. Copy of current plan or SPD with an outline of the proposed schedule of benefits, covered charges, exclusions and limitations. 4. Must provide: a) Employee Participation. b) Dependent Participation. 5. Present Rates and/or Rate History. Current TPA or ASO vendors, medical management and PPO firms and projected possible changes. 6. Name of Carrier for current and previous two years, From _________ through ________. 7. Monthly paid claims and average enrollment for previous period with employee count, claim experience, Specific claimants exceeding 50% of the lowest requested specific deductible, Large Claim Analysis Report with diagnosis/prognosis and any pended claims. 8. Disclosure Statement Shock Loss Details from the utilization review firm, sorted by ICD-9, pre-certified hospital encounters and concurrent Review Reports. 9. Cases 100+ lives. Census and distribution of census for all covered members including retirees and COBRA participants by age/sex, single/family, ZIP code. 10. Shock history, all claims over the specific requested for the past 2 years or more. 11. Requested Effective Date. 12. Contract Basis [ ]15/12 [ ]18/12 [ ]24/12 [ ]12/12 [ ]12/15 [ ]12/18 [ ]12/24. 13. Specific deductibles $25,000+ Requested Specific Deductibles. 14. Retired lives; If yes, how many. Should be noted on Census. 15. Disabled lives; If yes, how many. Should be noted on Census. 16. COBRA lives; If yes, how many. Should be noted on Census. 17. Employer Contribution EE (Employee)_______ DEP (Dependent) _______. 18. Renewal Rates. 19. PPO (Preferred Provider Organization) _______ (Name) 20. If multiple locations, how many participating in PPO’s _______.
S.L Where you should line up Cost of Specific 50,000 $ Fixed Cost 250,000 $ Specific Deductible Focus Here You 25% S.L Aggregate Variable Factors NOT rates 187,500 $ NOT here (as much)
run by fully insured personnel
Administrator, med management and network separate
binding, lower variable factors (that right side of the box).
contracted with on a proprietary basis?? Fixed cost is higher, with no flexibility or
as you demand, enables financial management by line item, lower fixed cost.
together, high variable factors, requires CURRENT good data, needs a top outside Quarterback (Broker or Consultant, maybe a TPA at QB, but typically NOT a good idea for a T.P.A. in that position.)
– “Trigger” reports – represent anybody hospitalized more than 15 days, It is critical that you have this and that it makes sense. – Aggregate reports – show the month, claims, # of people that month that had claims, large
line…not complicated, demand it!
Hand outs and References:
1) Stop loss 101 2) Handshake that changed health care history 3) ERISA Redux Carl Harker and Al George 4) *Met Life vs. Glenn 5) Self Funding of Health Care Benefits, Carl Harker FSA (Book upon request)