Looking to create a comprehensive plan design that accounts for every possible scenario?
You’re not alone – sometimes, it’s the little things that keep us up at night.
At Personify Health, one of our goals is to help brokers and their clients tackle any challenge they might face in the plan development process. We work with brokers daily, providing insights and solutions to help make the plan design season as seamless as possible.
With that in mind, we’ve compiled a list of seven essential questions to consider when crafting a plan design that meets all your needs. By keeping these questions top of mind, we can ensure that everyone involved can rest easy, confident in a successful outcome.
Ensuring Consistency is Crucial
1. Do plan documents and network contracts align when it comes to coverage?
Have you spotted any disparities between plan documents and network contracts regarding coverage?
When discrepancies arise between these documents, it opens the door for provider networks to bill for services not covered by the plan.
Consider this scenario: the plan mandates a pre-certification before an MRI, but the network’s contract doesn’t include this requirement. As a result, the provider declines to obtain the pre-certification, citing the absence of such a mandate in their contract. Consequently, the plan cannot process the claim without it, leaving the member caught in the middle.
Inconsistencies like these can have significant implications, highlighting the importance of aligning plan documents and network contracts to avoid such predicaments.
2. Are the provisions for appeals in your network contract aligned with the guidelines outlined in your plan document?
It’s common to find mismatched claim submission or appeal deadlines between network contracts and plan documents. These inconsistencies can result in significant financial setbacks for employers, particularly through stop-loss denials. The key here is to structure your plans so that deadlines sync up with those set in your contracts.
Consider this scenario: An employer’s network permits a generous four-year window for providers to file appeals on a plan-priced claim. However, this extended deadline surpasses the timeframe outlined in the plan document. Subsequently, when the belated appeal finally arrives, the stop-loss policy coverage has lapsed, rendering the claim ineligible for reimbursement.
The misalignment between the plan document and the appeals process outlined in network contracts resulted in a substantial loss for the plan sponsor.
Aligning these deadlines is critical to preventing such costly mishaps and ensuring smoother claims processing for all involved.
3. Do the guidelines outlined in the employee handbook align with those detailed in the plan document?
It’s essential to check if the provisions in the employee handbook align with the plan document.
Why is this crucial, you ask? Well, any discrepancies could lead to unexpected losses for the plan.
Imagine this scenario: the employee handbook allows for an additional eight weeks of approved medical leave beyond what’s required by FMLA and other regulations. To ensure seamless coverage for medical benefits during this time, the employer’s leave policy should be clearly reflected in the plan document.
If these details are missed in the plan document, it could result in significant and costly claims that won’t be covered by the stop-loss carrier. Without evidence that the employee was indeed covered by the plan during the extended leave, they may be deemed ineligible for benefits.
By ensuring coherence between the handbook and the plan document, we pave the way for smoother operations and avoid potential setbacks down the road.
Always Keep Members in Mind
4. Does your plan design provide the flexibility for members to access all necessary services?
Are you keeping members’ needs at the forefront?
Sometimes, plan designs fall short of accommodating what members truly require or in supporting a cost-effective approach that benefits the plan overall.
Consider this scenario: a limit on physical therapy sessions could potentially lead to more expensive treatments, like surgeries, when a few extra visits could have done the trick. Similarly, boosting home health visits might prevent a patient from having to revisit a skilled nursing facility.
Integrating an “alternative benefit” provision in the plan can bridge these gaps, ensuring that members receive tailored care while optimizing costs for the plan as a whole. By prioritizing flexibility in plan designs, we can champion the best outcomes for both the member and the plan.
5. Are members feeling overwhelmed and frustrated due to the numerous variations in plan design?
Ever wondered if the complexity of plan designs could leave members feeling bewildered and dissatisfied?
Well, the truth is, the more intricate the plan, the higher the chances of confusion and frustration creeping in among members.
Not to mention, managing complex plan designs can be costlier compared to simpler alternatives. Juggling multiple co-pays and deductibles may end up causing more hassle than they’re worth.
Simplifying by maintaining a uniform co-pay and deductible for office visits and inpatient care can lighten the load for everyone involved.
On the flip side, there are instances where a more intricate plan design is necessary to align with the goals of the plan sponsor.
Picture this: a company with various subsidiaries, different employee categories, and a desire to offer varied options to these groups. Some organizations opt for a basic plan with the option for employees to upgrade to a more comprehensive plan by paying the difference. The sponsor might decide to include coverage for specialized services like fertility treatments but with higher co-pays or deductibles compared to other benefits.
When dealing with multiple benefit levels, it becomes even more crucial to craft member communications that are crystal clear and easily understandable.
By streamlining plan designs and ensuring clarity in member communications, we can foster a smoother experience for members while also meeting the diverse needs of plan sponsors.
6. Do members sometimes find themselves facing hefty co-pays or unexpected bills because they aren’t sure how to confirm if a provider is within their network?
It can be disheartening for members when they find themselves burdened with unexpected bills or mounting co-pays, all because they didn’t realize how to verify if a provider is within their network. But there’s a solution waiting to be unlocked.
You see, oftentimes, members unintentionally face this predicament because they ask the wrong question when interacting with a provider. They innocently inquire, “Do you accept my plan?” and, unfortunately, the answer can be deceptive. That’s because accepting the plan doesn’t necessarily mean the provider is actually in the network.
Here’s a possible scenario: A doctor recommends an outpatient surgery center, where they may even have a financial interest. The member diligently asks the facility, “Do you accept my plan?” and receives a confident “Yes” in response.
But here’s the kicker: the center is not part of the network, which significantly inflates the cost of the surgery compared to a hospital. Suddenly, the member finds themselves presented with a shocking bill of thousands of dollars, covering out-of-network charges for a service that is already priced above market value.
And it doesn’t stop there. Similar situations can unfold with urgent care or laboratory expenses, leaving members understandably upset, angry, and inclined to point fingers at the plan itself.
The solution lies in member engagement, empowering individuals with the knowledge to ask the right question: “Are you in my plan’s network?” It may sound simple, but this shift in communication can make a world of difference.
While this education may not be mandated in the plan design itself, it can be seamlessly integrated into member materials, Explanation of Benefits (EOB) statements, workplace signage, and meaningful telephonic discussions. Starting this conversation as early as possible, ideally during open enrollment, alongside discussions about deductibles and co-pays, will set members on the path to becoming confident navigators of their healthcare journey.
7. Is the plan tailored to address the distinct regulatory and legislative considerations affecting certain populations and their coverage requirements?
A prime example of such complexities arises in the coverage of Native American tribes.
Typically, these tribes adhere to Federal plan guidelines, but variations exist, such as the potential to adhere to Medicare rates if a clinic is present at the reservation. Moreover, specific guidelines apply to tribal members, differing from those applicable to non-tribal members employed at a casino. Involving experts well-versed in Native American coverage matters can ensure seamless alignment of all regulatory prerequisites with the plan’s design.
At Personify Health, we work to steer clear of pitfalls, simplify plans for increased member engagement and comprehension, and meet the specific needs of plan sponsors. Our goal is to ensure clarity, enhance engagement, and provide tailored solutions that benefit everyone involved.
With global reach and local understanding, we can help you bring proven solutions to your clients—and adapt them to meet unique regional needs.