HHS Announces 2017 Out-of-Pocket Maximums

Money and gavelThe Department of Health and Human Services (HHS) has announced the 2017 out-of-pocket maximums applicable to self-funded and fully insured employer health plans. The maximums for 2017 have been set as follows:

  • Individual coverage: $7,150
  • Family coverage: $14,300

All non-grandfathered health benefit plans in effect on or after January 1, 2014 are required to comply with the Affordable Care Act’s (ACA) mandate that employer health plans’ annual in-network out-of-pocket maximums not exceed HHS’ established limits. The 2017 limits represent an increase from the current 2016 maximums of $6,850 for individual coverage (an increase of $300), and $13,700 for family coverage (an increase of $600).

The out-of-pocket limits represent the maximum amount that an enrollee must pay for covered essential health benefits through cost-sharing. It typically includes the annual deductible as well as any cost-sharing obligations the enrollee must meet after the deductible has been satisfied. The out-of-pocket maximum does not include premiums, cost sharing associated with of out-of-network services, or the cost of nonessential health benefits.

According to a recent study by United Benefits Advisors (UBA), out-of-pocket costs have increased significantly over the past decade, although median plan limits have remained below HHS’ out-of-pocket maximums. According to UBA, both individual and family coverage plans saw significant increases in median in-network plan out-of-pocket maximums in 2015. It is expected that out-of-network expenses will continue to increase significantly as well, as employers continue to widen the cost-share gap between employer and employee responsibilities.

For solutions to help mitigate employee health benefit plan costs that don’t simply shift costs to valued employees, contact the benefits experts at POMCO today.


Congress Delays Cadillac Tax Until 2020

BusinessmanPresident Obama has signed into law a two-year delay of the Cadillac Tax. The delay is part of Congress’s $1.8 trillion omnibus spending deal, the Consolidated Appropriations Act of 2016. In response to strong concerns expressed by employers and labor groups regarding the potential negative financial impact of the tax, Congress proposed the two-year delay.

The Cadillac Tax was added to the Internal Revenue Code by the Affordable Care Act (ACA) and was originally slotted for 2018. It is a 40 percent excise tax on the health plan value  that exceeds $10,200 for individual coverage and $27,500 for family coverage. The tax would be imposed on applicable employers, health insurers and “persons who administer plan benefits.” The Consolidated Appropriations Act also makes the Cadillac excise tax deductible for those entities required to pay it. The tax was originally enacted as non-deductible, so the change in tax status will potentially ease the burden to some applicable employers.

The Consolidated Appropriations Act also authorizes the U.S. comptroller general and the National Association of Insurance Commissioners to study whether the ACA uses appropriate benchmarks to determine whether the tax should be adjusted to reflect age and gender factors when setting excise tax thresholds.

Over the past several years employers have started making strategic benefit plan decisions to avoid the pending tax, such as shifting costs to members, reducing benefits, or transitioning to high deductible health plans. Even though the tax has been delayed, employers are still encouraged to work with their benefits administration partners and brokers to assess whether their health benefit plan is at risk of being subject to the tax so that adjustments can be made prior to its eventual enforcement.

It is anticipated that the two-year implementation delay will provide time for further examination of the proposed Cadillac Tax law to allow Congress and the new Administration to further examine and consider how best to execute the proposed tax. Some are still hopeful that the tax will be repealed before January 1, 2020.


Deadline for ACA Reporting Extended

Quantifying the Population Health Management Investment

The Internal Revenue Service (IRS) has extended the deadline for applicable employers and other health coverage providers to furnish 1094 and 1095-B and C series forms required by the Affordable Care Act (ACA). The deadline for furnishing individuals with 2015 Form 1095-B and 2015 Form 1095-C has been extended from February 1, 2016, to March 31, 2016. The IRS’s recent notice also extends the due date for employers and other health coverage providers to file with the IRS 2015 Form 1094-B and 2015 Form 1094-C from February 29, 2016, to May 31, 2016, if not filing electronically, and from March 31, 2016, to June 30, 2016, if filing electronically. Any employer filing 250 or more forms is still required to file electronically.

The extension provides employers with more time to gather the necessary data to generate and submit the required forms. Some of the ACA’s reporting requirements apply only to large employers (those with 50 or more full-time employees or full-time equivalents) and are meant to demonstrate compliance with the employer shared-responsibility mandate (“Pay or Play”) and eligibility for premium tax credits. Other reporting requirements apply to all employers, insurers, or other coverage providers that provide employees with minimum essential coverage to enable the IRS to enforce the individual mandate.

The extension provides a small measure of relief to many employers or their vendors, if applicable, who were in need of additional time to aggregate and calculate the data necessary for reporting purposes. The IRS forms require employers and other coverage providers to gather detailed information such as an employer’s monthly offer of health coverage to full-time employees, the employee’s share of premium, monthly enrollment information for covered individuals, their spouses and dependents, and identifying information such as tax identification numbers, and addresses, for example.  As this is the first year employers were required to document such data, many are still formulating processes to accumulate the information needed.

The IRS will still accept filings of the information returns on Forms 1094-B, 1095-B, 1094-C, and 1095-C beginning in January 2016 from any entity prepared to submit in January. The IRS intends to take a good-faith enforcement approach to this first year of reporting, however it is important to note that employers that do not meet the extended deadlines will still be subject to ACA penalties for failure to timely furnish and file the required forms. Employers utilizing software or payroll vendors to assist with their IRS filings should confirm with their vendors any applicable deadlines for data submission.


A CFO’s Guide to Making Benefit Plan Determinations

What Questions Should You be Asking?

Simplifying AdministrationEmployee benefits are one of the most significant bottom line costs for any organization. Chief financial officers play an essential role in determining what benefit plan solutions not only fit into the organization’s budget, but have the potential for the greatest cost savings. As you plan for the coming year’s expenses and work with your human resources director and benefits consultant to determine the right employee benefit solutions for your employees, ask the following questions:

Is our current health benefit plan at risk for the Affordable Care Act’s (ACA) Cadillac Tax?

The Cadillac Tax is a 40 percent excise tax on employer-sponsored health plans with annual premiums in excess of $10,200 for individual coverage, and $27,500 for family coverage. The mandate is set to go into effect in 2018¹, leaving employers only two full calendar years to make plan changes in order to avoid the tax. For organizations that are collectively bargained in particular, it may be necessary to begin negotiations and planning now, in order to avoid the tax in 2018. To mitigate the risk of the tax, some employers are choosing to restructure benefits, move to narrow networks, or offer a high-deductible health plan (HDHP) in order to reduce overall plan costs and health plan value.

What is the cost of our spousal coverage?

According to BenefitsPro, the average cost of providing health care for a family was $16,351 in 2013, a 4 percent increase from the year prior, and employees paid, on average, only $4,565 of that total. As part of a trend to not only reduce overall health care costs, but also as a strategy to further avoid Cadillac Tax implications, a growing number of employers are restricting spousal benefit coverage by implementing a working spouse rule. The rule stipulates that if the spouse of an employee has access to primary health care through his/her own employer, and the employer pays for a designated portion of the single coverage cost, the spouse is not eligible for coverage under your plan. As an alternative, some employers are allowing spouses to remain covered, but are adding a surcharge to the cost for the employee. CFOs should weigh the cost benefits of a working spouse rule against how such a significant change may be viewed by employees. Though bottom line costs are a priority, recruitment and retention of talent must be considered with every benefit decision.

Are we conducting eligibility audits?

One of the largest causes of benefit leakage is outdated or inaccurate coordination of benefits. Employees may inadvertently fail to notify their employer of a change in their dependent’s status, but regardless of the reason, employers have an obligation to protect their health plan by ensuring that claims are not paid to anyone who is not truly eligible for coverage. Eligibility audits are a helpful tool for identifying such scenarios as dependents that have exceeded the plan’s age limit, a change in marital status such as a divorce, or cases when a child is not a legal dependent per the terms of the plan, such as a nephew or grandchild. According to Employee Benefit Advisor, a dependent eligibility audit can provide a typical ROI of nearly 15 percent and millions of dollars in cost savings. Organizations should conduct an eligibility audit at least every four years in order to identify enrollees who, per the plan guidelines, should no longer be eligible for coverage

Have we considered self-funding?

According to the Kaiser Family Foundation’s 2014 Employer Health Benefits Survey, more employers are self-funding their employee benefits, and that number has been on the rise. According to Kaiser, 15 percent of covered employees at small companies with 3-199 employees, and 81 percent of covered employees at larger firms, are enrolled in plans which are either partially or completely self-funded. CFOs should consider the advantages of self-funding, which include a greater flexibility in plan design and benefit options, access to actionable claims data, and lower administrative costs. Self-funding also provides enhanced cash flow options. Unlike fully insured plans that require advanced premium payment, under a self-funded plan, claims can be funded as they are due, which allows employers to keep more money in a bank account where it can earn interest.

For a health benefit plan assessment and customized cost-avoidance solution for your health benefit plan, contact the benefit experts at POMCO today.


¹ After this article was published in December 2015 Congress delayed the Cadillac tax until 2020. Read more here.



The Cost of Polypharmacy

The cost of polypharmcyPolypharmacy is a term used to describe the use of four or more medications by a single patient. It typically occurs in patients managing a chronic condition, or in a patient who is over 65 years of age. Affecting approximately 40 percent of seniors, polypharmacy poses significant health risks, including drug-interactions, and dosing errors. For health plans, not only are higher numbers of prescribed medications costly, but the risk of adverse reactions could result in additional incurred costs in the form of hospitalizations. By understanding the risks of polypharmacy, and by partnering with an administrator with nurse case management capabilities, the risks and costs of polypharmacy can be mitigated.

According to pharmacy benefits manager Express Scripts, the average senior utilizes six different medications, and more than 15 percent of seniors use at least 10 different medications simultaneously. One common scenario in which polypharmacy occurs is when a patient is being treated by multiple physicians who are unaware of one another’s prescription treatment plans. A study by Express Scripts found that seniors being treated by two different physicians had an average of 27 prescription fills and were at-risk for 10 medication errors each year. For patients being treated by as many as seven physicians, their average number of prescriptions increased to a staggering 52, with the potential for 22 annual medication errors. Other causes for polypharmacy may include:

  • Interaction with other drugs that require treatment from a third drug, a scenario called “cascading drug therapy”
  • Inadequate screening for drug allergies
  • Inappropriate dosing strength based on the patient’s age, size or health status
  • Use of expired medications
  • Use of over-the-counter or alternative treatments

When a patient is utilizing so many different medications, there is the potential for increased side effects and even reactions that contradict one another, or that a drug being used for one condition will have a negative impact on another health problem. For example, a medication used to manage diabetes may negatively impact heart function and may not be appropriate for a patient at-risk for heart failure. In addition, patients prescribed four or more medications often report that they find it difficult to remember when to take each drug, leading to complications associated with inappropriate medication use and non-adherence.

In addition to the severe risks for the patient, employer health plans are at-risk for significant costs associated with not only higher drug utilization patterns, but the potential for health complications caused by mixing so many medications. Polypharmacy can harm a patient’s health, resulting in increased doctor visits, emergency room visits, and inpatient stays. According to OptumRX, medication misuse and polypharmacy cost the United States more than $177 billion in unnecessary visits to the doctor, the emergency room, and the hospital every year.

Patients managing one or more chronic conditions do not need to struggle to follow their treatment plans alone. For employers partnering with a benefits administrator that offers nurse case management services, an on-staff registered nurse can assist at-risk patients to manage their condition. A nurse case manager may:

  • Conduct a medication review that includes over-the-counter medications
  • Assist in coordinating care and treatment plans among multiple physicians
  • Educate the patient and his/her family members on risks of overdosing, underdoing, and non-adherence
  • Assist the patient in finding generic substitutions, if applicable

By engaging a nurse case manager, at-risk patients are more likely to use medications appropriately, and use less of them for shorter periods of time. By helping to make each patient’s medication treatment plan as efficient as possible, employers can mitigate the impact of avoidable drug and health care costs and reduce their overall bottom line.


The Growing Trend of Telemedicine

Blonde woman at laptopWe will always have a need for high quality, accessible health care provided by knowledgeable and compassionate physicians and care providers. What is changing, however, is access to such care. There is not only an increase in the number of available telemedicine, or virtual providers entering the health care marketplace, but an increase in adoption of such services, as tech-savvy consumers are becoming more comfortable with the idea of a virtual doctor’s visit conducted via video conference. According to HIS, an information and analytics firm, cumulative annual growth of video consultations between primary care providers and their patients is expected to crease by nearly 25 percent a year over the next five years to 5.4 million by 2020.

As a benefit to employees and health plan members, telemedicine services provide convenient access to quality health care providers and physician consultations, especially for minor ailments, mental health services, dermatology, and smoking cessation services. Rather than waiting for a doctor’s office appointment, which may book weeks or even months in advance, or seeking care at a costly urgent care center, patients can schedule a virtual consultation, typically within a short window, and receive more immediate and cost-efficient advice and care.

In addition, based on a study conducted by the journal Telemedicine and eHealth, telemedicine services have been proven to reduce:

  • Emergency room visits
  • Hospital admissions and readmissions
  • Average lengths of stay
  • Mortality rates

The study aimed to analyze the benefits of telemedicine services specifically for patients with three chronic conditions: congestive heart failure (CHF), stroke, and chronic obstructive pulmonary disease (COPD).

As a benefit to the employer, providing convenient access to physician care helps ensure members are diagnosed for risk factors that, if left untreated, could result in a catastrophic event and high dollar claims in the future. According to Towers Watson, telemedicine services could save employers more than $6 billion a year in health care costs. To maximize savings, a health plan population would need to use telemedicine services exclusively in place of in-person doctor’s office visits, urgent care visits, and emergency room care. However, telemedicine services have perhaps been most efficiently utilized by employers as part of a broader and fully integrated population health management solution that includes other interventions across the care continuum such as online wellness tools, onsite/near-site clinics, disease management services, and wellness coaching. Such a platform ensures at risk members are more quickly identified and provided with appropriate care, given their unique needs and risk factors.


Does Your Consumer-Driven Health Plan Put You At Risk for the Cadillac Tax?

Affordable Care Act (ACA), Out-of-Pocket-MaximumsThere are significant questions regarding 2018’s potential Cadillac Tax in the minds of employers across the nation. The Affordable Care Act’s (ACA) proposed 40 percent excise tax on high cost plans has the potential to either significantly add costs to employers’ health plans, or require a shift of costs to members in an effort to avoid the tax – something many employers are hesitant to concede. Aside from the potential impact to health benefit plans, new insight indicates that the Cadillac tax may impact employers’ abilities to offer consumer-driven health plans (CDHP) such as flexible spending accounts (FSA) and health savings accounts (HSA). Read on to prepare your benefit strategy prior to 2018.

Potential Impact to FSAs

The Cadillac tax intends to levy a 40 percent penalty on health plans with annual premiums in excess of $10,200 for individual coverage, and $27,500 for family coverage. The tax applies only to the portion of the plan cost that falls above those thresholds. Since the maximum FSA contribution limits, which are estimated to be $2,700 by 2018, are typically additive to other benefit costs for employees that elect contributions, the cumulative cost of coverage between health and FSA plans could easily trigger the penalty fee for generous health plans. For this reason, some employers are considering terminating their FSA benefit, but maintaining their health benefit plan structure.

According to BenefitsPro.com, a recent survey of hospital management personnel identified that many hospitals intend to remove their FSA plans from their benefit plan offering if the ACA’s Cadillac Tax goes into effect in 2018. This potential trend is because FSA benefits may have an impact on triggering the Cadillac Tax penalty. According to the Kaiser Family Foundation, an estimated 26 percent of employers anticipate that their FSA offering may, in part, trigger the excise tax.

As an alternative solution to canceling an FSA plan entirely, other employers are considering re-structuring their FSA to only allow employer contributions, or to limit the employee’s contribution below the maximum IRS thresholds, thus diminishing the risk that an employee’s additional contribution may push the employee’s total cost of overage over the Cadillac Tax’s acceptable limit

Aside from FSA plan reductions, employers may also want to consider reducing such pre-tax ancillary health benefit options as critical disease or hospital indemnity plans.

Potential Impact to HSAs

As the proposed ACA mandate currently stands, employer and employee contributions to HSAs are also subject to the Cadillac Tax’s threshold limit. While the popularity of HSAs coupled with high deductible health plans (HDHP) have been on the rise as employers look for solutions to mitigate their overall benefit plan costs, HSAs, when coupled with employer pre-tax contributions, may now increase an employer’s risk of being subject to the 40 percent excise tax.

Similar to the decisions facing employers offering FSAs, employers are considering reducing or eliminating their pre-tax contributions to their employees’ HSA accounts in order to avoid reaching the Cadillac Tax’s threshold. Such a trend could reduce the effectiveness of HSAs as a successful strategy for employees to reduce their out-of-pocket health care costs. It may also limit opportunities for employers to incentivize population health management program initiatives in the form of HSA contributions – an employee engagement strategy that has been extremely successful in increasing wellness program participation.

Potential Changes in the Future

As a result of concerns expressed by organizations that the Cadillac Tax may impact their ability to help employees pay for quality health care expenses, many benefits professionals are advocating for benefit accounts to be excluded from the threshold limits before the Cadillac Tax goes into effect in 2018.  In addition, there is still hope that the United States Treasury Department and the Internal Revenue Service (IRS) will delay enforcement of the tax through extended transition relief.


Understanding Permanent Partial Disability Claims in Workers’ Compensation Plans

Permanent Partial Disability ReimbursementOver half of all workers’ compensation claims nationwide are accounted for by permanent partial disability (PPD) claims. Having an understanding of the causes of these types of disabilities, and the workers’ compensation benefits available to injured workers, will help you successfully partner with your workers’ compensation benefits administrator on the effective, cost-efficient, and equitable management of your workers’ comp plan.

PPD Claims Defined

PPD claims may be caused by either an occupational disease, such as asbestos or lead poisoning, or a work-related injury. In order for a claim to be classified as a PPD claim, some form of permanent impairment must exist which results in a worker’s inability to perform his/her job to full capacity. It is not a permanent disability, which occurs when a worker can no longer work in any capacity, or is presumed to be totally disabled due to a loss of both hands, eyes, or total paralysis. In the case of a PPD, a portion of the employee’s wage-earning capacity has been permanently lost due to his/her disability, and thus compensation is due to the injured worker for a period of time.

Types of Injuries Resulting in PPD Claims

Some of the most common types of injuries or medical conditions that result in PPD claims include:

  • Back injuries
  • Carpal tunnel syndrome
  • Amputations such as of the finger or hand
  • Hearing loss
  • Loss of vision in one eye
  • Knee injury
  • Nerve damage
  • Post traumatic stress disorder (PTSD)


While compensation parameters vary by state, the amount of financial compensation that a partially permanently disabled worker is entitled to under a workers’ comp plan depends upon the severity of the disability, according to a doctor’s rating. To determine compensation amounts, many states utilize a disability schedule, including New York, and California. The extent of a worker’s disability is determined as a percentage, with greater compensation being given for a greater percentage for disability. For example, a worker with a 75 percent disability will receive a great amount of compensation than a worker with a 25 percent disability.

Understanding Types of PPD in New York State

In New York State, there are two types of PPD benefits: schedule loss of use (SLU), and non-schedule. The two types of disability are differentiated by the part of the body affected by the injury, and the nature of the permanent disability. The severity of the disability is measured when it is determined that the worker has reached maximum medical improvement (MMI), or the state in which an injured worker’s condition cannot be improved any further, or when a patient’s healing process treatment has plateaued.

SLU: Occurs when a worker has permanently lost the use of an upper extremity, such as an arm, finger, or shoulder, a lower extremity, such as a knee, ankle, or foot, eyesight or hearing. In cases where SLU benefits are applied, compensation is limited to a certain number of weeks based upon the body part and severity of the disability

Non-schedule: A permanent disability involving a part of the body or a condition that is not covered by an SLU award, such as the spine, pelvis, lungs, brain, etc. Non-schedule benefits are based on the employee’s permanent loss of earning capacity.

In New York State, for non-schedule claims, if the work-related accident or date of disablement occurred before March 13, 2007, benefits are payable as long as the partial disability exists and results in wage loss. If the work-related accident or date of disablement occurred on or after March 13, 2007, then benefits are payable for a maximum number of weeks as determined by the claimant’s loss of wage-earning capacity.


Projecting the Impact of the Proposed Cadillac Tax on Employer Sponsored Health Coverage

Quantifying the Population Health Management InvestmentOne aspect of the Affordable Care Act (ACA) that has been looming large in the now foreseeable future is the “Cadillac Tax,” a 40 percent excise tax on employer-sponsored health plans with annual premiums in excess of $10,200 for individual coverage, and $27,500 for family coverage. The tax applies only to the portion of the plan cost that falls above those thresholds, and was proposed in the initial ACA regulations passed back in 2010. For years, employers have been warily waiting for final regulations to be issued regarding the Cadillac Tax, and some have even hoped that the regulations may be changed significantly to reduce or remove the tax. As we enter 2016, however, the Cadillac Tax is still anticipated to become a mandated requirement in 2018. Employers are working with their brokers and benefits administration partners to project how the Cadillac Tax could impact their health plan, and are making changes to mitigate the potential cost impact.

The purpose of the Cadillac Tax is to reduce overall health care costs and reduce the tendency of companies to provide rich health care benefits to employees as a form of compensation that is not taxed at the same level as ordinary income. Utilization trend data indicates that overly generous health plans lead to over-utilization of health care services, which in turn, increase overall health care spend nationwide. By encouraging employers to move away from overly-rich benefits, the Cadillac Tax hopes to encourage individual plan members to become more responsible, cost-conscientious consumers of health care services.

While this is a goal that has the theoretical potential to financially benefit employers and their health plans, many organizations are casting a worried eye toward the impact reducing their benefits will have on their valued employees. The Cadillac Tax’s requirements are particularly concerning for collectively bargained plans with long-standing negotiated benefit plans. If employers at risk of being subject to the excise tax do not make benefit changes, however, they stand to incur significant costs in the form of penalty tax dollars.

The Congressional Budget Office estimates that the total liability for companies subject to the tax could reach $79 billion from 2018 and 2023, and according to Forbes, 40 percent of employers expect the Cadillac Tax to affect at least one of their current health plans come 2018, while 14 percent expect it to immediately impact the majority of their current health benefit plans. Further, according to Mercer, approximately one third of employers are at risk of paying the Cadillac Tax in 2018 if they do not make adjustments to their health benefit plan costs, and that percentage may increase to as much at 50 percent by 2018.

In addition to the financial impact of the excise tax itself, the Cadillac Tax will further financially impact employers in the form of administrative costs. According to new guidance issued by the Internal Revenue Service (IRS), it is considering two approaches to determine which entity must actually remit payment for the tax — the “insurer,” or for self-funded plans, the employer. Under the other approach being considered, the employer would calculate the tax and direct any applicable plan administrators to pay the portion associated with the plan they administer. Regardless of the final regulatory outcome, the administrative requirements associated with calculating and reporting potential tax implications may significantly impose administrative and financial burdens on many employers.

Given the potential for both tax and administrative cost requirements, many employers may decide they need to lower their health care costs by reducing their health benefit cost share in order to ensure overall affordability of their plan. According to Bloomberg Business, after several years of shifting health care costs to employees, organizations are slowing their adoption of high-deductible health plans (HDHP) in part because they are waiting to see if lawmakers repeal, or revise, the terms of the Cadillac Tax. If the Tax is not repealed, it is anticipated that the increasing trend of offering HDHPs as options or even full replacements to traditional PPO plans is likely to continue in 2018 and beyond.

Other strategies that some employers are implementing to mitigate health plan costs include implementing a working spouse rule, in which employees pay a higher premium to enroll a spouse who has coverage available from his/her own employer – or not allowing the spouse to enroll as primary, or even as secondary, at all. In addition, employers are adding population health management programs to encourage healthy behavior in an effort to reduce risk factors that could lead to high utilization patterns or catastrophic claims.

As 2018 approaches, many employers will be faced with a difficult decision: reduce employee benefits, or face significant tax penalties. For strategic recommendations for mitigating health plan costs without compromising on the quality of your health benefit plan offering, contact the benefits experts at POMCO.


The Benefits of a Total Solutions Provider.

Total Solution ProviderAs organizations search for the most effective ways to manage their benefit plans, they may find short-term benefits, such as incremental cost-savings, in working with a variety of vendors to achieve their goals. However, obtaining optimal plan performance requires advanced knowledge of the multiple aspects of a full benefit solution. The implementation of a benefit plan that assimilates disparate services results in increased costs associated with reduced service and missed opportunities to contain costs. The following document outlines the many benefits associated with partnering with a total benefit solutions expert in order to fully mitigate risks and drive down costs.

Risk Management Across the Spectrum for Enhanced Transparency

To mitigate risk across all employee benefit services, risk management services such as workers’ compensation, medical bill audit, and nurse case management should be integrated into the benefit solution to fully contain costs.  Integrating all related risk management services with the health benefit plan results in a solution that is able to allocate member claims appropriately. For example, an integrated solution will identify when an employee’s doctor visit is associated with an injury that was the result of a workers’ compensation claim, and make sure the claim is not erroneously paid as a health claim.

Fully Integrated Benefits Administration

The full spectrum of services that encompass an effective benefits solution are vast:  medical, dental, and vision; pharmacy integration; case management; utilization management and review; population health management; on- and near-site clinics to name a few. The more services that are a part of an overall benefit solution increases the complexity involved in its administration. In addition, services that are decentralized and do not feed into a shared technological platform must be analyzed singularly, therefore, hindering the effectiveness of comprehensive predictive modeling. Enhanced program optimization relies upon advanced technology that not only serves as the single location for plan data, but stratifies that data accordingly to identify every opportunity to reduce costs.

Account Management – The Expert in the Benefit Solution 

Arguably, the most important aspect of an effective benefit solution is the expertise of the account manager. When services are fully integrated, the advanced knowledge of the account manager is even more important to the full optimization of the program. Account managers with extensive industry knowledge that spans the full breadth of the services within the solution produce the most effective recommendations for risk mitigation. In addition, they are equipped with the analytical expertise to review plan performance metrics of all implemented services, such as medial plans, prescription drug plans, disease management, case management, and population health management, to identify trends and gaps in care that are driving plan costs. When an administrator only manages one piece of the puzzle, their analytics are limited to only those cost factors in their scope of service, which means there could be compounding factors left unaddressed.