Group Health/Medical

Group Health/Medical

FULLY INSURED PLANS

1.  If you have 50 employees or less with your business and offer benefits, you are probably in a Fully Insured Plan. 

2.  In North Carolina, Blue Cross Blue Shield and United Healthcare are the only two fully insured plans with employees less than 50.

3.  There is no underwriting with these plans.  They can go down to 2 employees for both United Healthcare and BCBS.  BCBS will allow an employer sponsored health plan to go to one employee in NC.

4.  There is no underwriting with these plans.  Plans can be both composite or age banded.   Age, Zip Code and Smokers are the only ways employees can be rated.

5.  You, as an employer may still have a Grandfathered fully insured plan in place. 

LEVEL FUNDED PLANS

1.  The Plan is “Level Funded” so by design, any risk to the sponsoring employer has been removed beyond the 12 months paid.

2.  Specific and aggregate custom stop-loss insurance coverage, participating employers are able to gain the flexibility they desire without taking on the risk.

3.  Underwriting keeps cost contained and LFP intact for participating employers for the long term. 

4.  LFP’s can come in as much as 50% less than Fully Insured plans.  Average is 30%.  Renewals 3% average with potential Return of Premium.

ASSOCIATION PLANS

1.  Small Employers, including sole proprietors, will be able to be part of a group plan structured based on geography or trade/industry.

2.  Some association plans are in place.  New association plans with fully insured structure allowed Sept 1, 2018. Self Funded Assoc plans permitted April 1, 2019.

3.  Plans must meet typical requirements for a regular  employer sponsored health plan.  The plans have set composite rates and are guaranteed issue. 

4.  IP wants The AHP to be structured under an association administered under organizations like a PEO or ASO for security of the plan. 

REFERENCE BASED PRICING

Insurance claims today typically have large discrepancies between what providers charge for care and what is ultimately paid by the insurance carrier.  This difference or “discount”, is what insurance carriers promote as the savings they provide to the employer groups through their provider negotiations.

The issue is that even after the promised discount, the paid amount is often significantly greater than what Medicare pays. Some for-profit health systems charge up to 10 times what Medicare pays.

The RBP model, the employer sets a maximum amount that they’ll pay for a claim.  Most reference priced vendors reimburse claims based on what Medicare pays plus a specific percentage.  This helps plan sponsors cut costs by capping what the plan covers for some medical procedures where fees can vary widely.

CO-SHARE

The Co-Share Employer Solution | Sedera Health™ | Shared Health Alliance™

  • Combines Non-Faith Based Health Share with Shared Health Alliance Minimum Essential Coverage Solution
  • Employees have first dollar access and catastrophic reimbursement health share membership
  • Shared Health Alliance performs consolidated billing to employer - one bill
  • Shared Health Alliance Third Party Administrator does "warm transfer" for employees that need medical reimbursement from Sedera

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Main-line:    704-375-1112

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Hamilton Edwards, Inc.
604 Southern Pine Blvd.
Charlotte, NC 28273

[email protected]

 

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