Other Services

With a partially self-funded plan, the employer assumes a professionally calculated amount of risk (claims). Stop loss coverage is obtained to cover excess claims.

  • - Specific stop loss protects the plan against in individual catastrophic claim.
  • - Aggregate stop loss covers claims exceeding a given amount on the entire covered group.
  • - We offer access to very competitive stop loss markets.

Self-funding gives employers greater control, since their funds may be contributed to an employer-established account and transferred when needed to pay claims. Excess funds remain in the account and collect investment earnings. With a 501(c)(9) trust account, these earnings may accrue tax-free.

Lower Costs

While most of the savings realized from self-funding is created by enhancements in plan design and claims administration functions, the following cost-saving features also apply:

  • - Premium taxes - usually 2% to 6%, do not apply to self-funded claim funds in most states.
  • - Operating costs generally are lower.
  • - Insurance carrier profits and risk charges often are reduced.
  • - Self-funded programs are regulated by ERISA, eliminating many costs state-mandated benefits.

Claims Administration Means Maximum Output With Maximum Accuracy

In a self-funded environment where claims can represent as much as 95% of overall plan costs, no employer should settle for less than maximum output with maximum accuracy.

To accomplish these goals, we begin with talented, experienced claims professionals and support them with state-of-the-art computerized benefits administration technology.

Whether fully insured, self-funded or managed care, you can rely on us to provide totally automated service, including billing, claims processing and management reporting. Following are just a few of the procedures we perform to control costs:

  • - Employee eligibility is monitored regularly and verified instantly.
  • - Plan funds and checking accounts are tracked automatically; employers are notified when minimum levels are near.
  • - Duplicate claims payments are avoided through coordination of benefits with other group health plans.
  • - Medical logic technology and a team of clinical support nurses and physicians are available to monitor physician claims for compliance with currently accepted medical practice standards.
  • - Timely financial information is provided, including specific and aggregate stop-loss statistics.
  • - Provider payment information is automatically updated as payments are posted.
  • - Payment calculation capabilities range from reasonable and customary on surgery (HIAA, CRVS, FRVS, CPT) to defined benefit schedules.
  • - Performance of claims analysts is monitored through regular auditing.

In this day of increased government regulation, your administrator must be able to meet complex billing and regulatory requirements. Our computerized systems are parameter-driven, which means we are able to tailor billing procedures to your specific needs. We can direct billing to specific locations or divisions within your organization. The following functions also are available for each self-funded program we administer.

Complex Billing & Compliance Simplified

  • - We can bill multiple locations or divisions within your organization and maintain individual loss statistics or fund balances.
  • - We can facilitate your compliance with COBRA, which requires extending health care benefits to eligible departing employees, spouses and dependents.
  • - We can assist in issuing COBRA letters, notices and coverage applications, and in collecting and disbursing payments.

Timely Management Information

With annual health care costs at more than $4,000 per American worker, the need has never been greater for timely and easily understood plan and provider data. Our company has earned an excellent reputation for providing client employers with reports on:

  • - Eligibility - monthly payments issued - monthly claims paid
  • - Benefit analysis - coverage analysis - lag studies and cash analysis - 1099s and W-2s - provider payment analysis

Easing COBRA Compliance

Virtually all U.S. employers with 20 or more full or part time employees, who offer these employees a health care benefit plan, are subject to COBRA. This law, originally passed in 1985 as the Consolidated Omnibus Budget Reconciliation Act, was updated by Congress through passage of HIPAA in 1996.

Under COBRA, employers are required to let certain persons, known as "qualified beneficiaries," continue their health care coverage at the group rate for a specified period of 18, 29, or 36 months, depending upon the "qualifying event" involved. For this reason, we assist employers in complying with the requirements of the law. Our specific COBRA services include...

Tracking Time Limits...

We assist by maintaining employee and dependent data and generating timely notices as needed.

Notifying Eligible Employees...

We can assist in notifying all covered employees and spouses of their rights under COBRA and as "qualifying events" take place. We will also implement coverage as qualified beneficiaries elect continuation coverage.

And Calculating Costs.

Charges for continuation coverage cannot exceed 102% of the applicable premium for the coverage period. In a self-funded plan, the premium must be calculated on an actuarial basis or by determining the premium for a like-situated beneficiary for the preceding determination period, with proper cost of living adjustments.

Regardless of your funding strategy, our administrative experts will calculate premiums and generate all required written notices. Premium payments will be processed in accordance with strict control procedures and disbursed promptly.

HIPAA Coverage Certification Assistance

Under the Health Insurance Portability and Accountability Act of 1996, as long as covered employees meet certain requirements with regard to waiting periods, they are assured of insurability when they leave their job and move to another employer. This "promise of continuation of insurability" places additional obligations on the shoulders of both employers.

The former employer must track coverage "credits" and issue a certification of coverage as participants leave the plan. The new employer must accept such certification and apply it to the plan's pre-existing condition provisions.

Compliance With These Provisions Requires:

  • - Knowledge of the regulations, as well as the specific plan design
  • - Technology to track eligibility, waiting periods and coverage credits
  • - Strategies to ease the notification process and required employee communications

We have the systems and the expertise required to assist your organization with compliance in this area of employment law.

Design, administration, compliance assistance

We can assist your company with the design and administration of a Flexible Spending plan that is in full compliance with IRC Section 125. Examples of guidelines to consider:

  • - The plan must be in writing and offer employees a choice of two or more benefits consisting of cash and "qualified" benefits. We can help you design a plan that meets these and all other legal requirements, such as non-discrimination rules.
  • - Current rules provide that employees have access to their maximum Flexible Spending Account contribution at any time during a plan year. All refund requests for medical expenses must be documented in writing.
  • - Both the Internal Revenue Service and the Department of Labor require certain information, including annual information returns.

Point-of-Service Plans

These plans offer employees the ability to go outside a specific provider network for services, usually with a higher deductible or coinsurance contribution.

Throughout the plan design process, we will work closely with your accountant, legal counsel and financial depository to comply with existing government regulations and applicable bargaining agreements. We will help develop the Plan Document, Summary Plan Descriptions, Identification Cards and Administrative Forms. We also will assist in communicating the new plan to your employees, in a variety of media.

This is all part of our customized plan design service, which provides valuable coverage and cost control with added flexibility and communication.