What does a self-funded healthcare plan look like?
To create and manage a comprehensive healthcare plan, self-insured businesses will need a strong team.
Health Plan Consultants (Brokers)
A trusted advisor and consultant whose purpose is to advise on how to manage the health plan’s service providers that handle provider and facility claim payment and risk mitigation.
Health Plan Service Providers
Every health plan has two cost centers: medical and Rx costs (variable costs), and administration fees (fixed costs). Generally, a health plan has the following administrative service providers:
- Health Plan Consultants · This individual or team is responsible for ensuring the health plan runs smoothly for both the business and its employees. The consultant is responsible for vetting and bolting on the health plan service providers.
- Third-Party Administrator (TPA) · The benefits administrator handles employee medical and Rx claims for both reporting and funding purposes. A high functioning TPA is critical to the plan’s success.
- Pharmacy Benefits Manager (PBM) · The PBM manages all aspects of Rx utilization. The PBM is the front line defense, as Rx usage is a leading indicator of the plan’s risk profile.
Risk Mitigation/Wellness services
There are many service providers in this space with both a narrow and broad focus approach to medical and Rx cost control. The success of these service providers is largely dependent on each business’ ambition and culture.