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What is a TPA?

Occasionally, there is confusion in the marketplace about what a TPA does.

TPA stands for Third Party Administration—which means that we are a third party that administers employee benefit programs, including health insurance, from outside companies on behalf of employers.

In fact, Consociate Health partners with consultants and employers of all sizes as a trusted advisor to deliver innovative employee benefit programs, healthcare plan administration, consulting, and wellness initiatives.

As a licensed claims administrator, we provide administrative services for employer-sponsored health plans including enrollment and termination of plan participants. We also maintain plan records including tracking the status of claims as well as process claims.

We communicate with plan participants, authorized appointees, and health care providers. We maintain all patient information and other protected health care information in the strictest confidence.

The Plan Sponsor maintains current plan eligibility and records, and makes final decisions on doubtful or disputed claims.

To learn more about our unique cost containment strategies and award-winning standards for accuracy and service, contact us today.

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5 Strategies for Reducing Health Benefits Costs in 2021

Health benefits costs are almost certainly going to rise in 2021. They’ve been trending upward for years—over 50% in the last decade, according to the Kaiser Family Foundation—and the current state of economic uncertainty over COVID-19 won’t slow things down. Realistically, after enduring months of business closures and managing exhausted workforces, many employers will be lucky to maintain uninterrupted operations.

That’s why it’s critical for employers to think about reducing health costs right now—figure out cost-effective benefits first so money can be shuffled as needed later. Having a solid plan going into 2021 will better position organizations facing limited budgets.
Here are five cost-reduction strategies employers should explore:

1. Dig Into Health Costs
Employers don’t let themselves overpay for the materials they use during production, so why is health care any different? Employers should look into every health care figure they can, from overall premium costs to individual employee expenditures. Understanding where money goes can help focus cost-cutting efforts.For instance, if employees are going to the emergency room for every health visit, employers know they must promote more health literacy among their workforce. Speak with Consociate Health for details about digging into your health plan cost data.

2. Embrace Technology
The health care landscape of today is starkly different than the one of even a few years ago. Now, the name of the game is virtual health care or “telemedicine.” There are numerous ways for individuals to take charge of their health care without the hassle—and added cost—of in-person consultations. For example, there is tech that can monitor glucose levels to help diabetic employees without test strips; there are virtual visits available for doctors, psychiatrists and other health professionals; and there are countless wellness apps that can help individuals make proactive health choices.

3. Consider Alternative Plan Options
Not every plan option will work for every organization. For years, PPOs were the standard, but now high deductible health plans with savings options are having their moment. These plans enable greater heath consumerism and put the decision-making power into employees’ hands. Employers should consider offering mechanisms like HSAs, FSAs and HRAs to help shift costs without compromising health care quality.

4. Require Active Enrollment
Some organizations allow employees to passively enroll in their health benefits. This may seem like a nice timesaver, but it can actually hinder employee health literacy. Instead, employers should require active enrollment among employees. This approach would force employees to review all their benefits options each year before making selections. Not only does this make employees consider important life events, it also affords them an opportunity to reevaluate the benefits they’re paying for and potentially not using. Ultimately, active enrollment can make employees wiser health care consumers, improve proactive health care and lower overall health expenditures.

5. Change the Funding Structure
Another, more drastic, cost-cutting strategy is changing how health plans are funded. Most organizations use a fully insured model, where employers pay a set premium to an insurance provider, but that’s not the only option. For some employers, self-funding, level-funding or reference-based pricing models may be more attractive solutions.

Suffice it to say, there are a variety of ways that employers can structure their health plans—even if that means requiring employees to seek insurance in the individual health market. Whatever your needs, know that Consociate Health is here to help.

Contact us today to discuss your 2021 benefits.

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5 Ways to Support Employee Mental Health

Promote Mental Health Awareness in the Office

When you openly talk about mental health, employees are more likely
to feel comfortable about the concept, and reach out to managers or
co-workers if they’re struggling.

Offer Flexible Scheduling

Work-life balance, or a lack thereof, can affect an employee’s mental health. To help employees better balance their work and personal lives, employers across the country are embracing workplace flexibility.

Address Workplace Stress

Nearly 80% of Americans consider their jobs stressful. Common job stressors include a heavy workload, intense pressure to perform at high levels, job insecurity, long work hours, excessive travel, office politics and conflicts with co-workers. While it may not be possible to eliminate job stress altogether for your employees, you can help them learn how to manage it effectively.

Evaluate Benefits Offerings

Reviewing the offerings that your organization provides to ensure coverage for mental health services is essential to creating a culture that supports employee mental health.

Train Managers

To ensure that no stigma surrounding mental health exists at your organization, it’s important that you properly train management in recognizing the signs of mental illness, excessive workplace stress, workplace bullying and fatigue.

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Health Insurance Terms You Need To Know M – Z

The health care system in the United States can be confusing. In order to get the most out of your health care benefits, you need to understand the terms used by insurance companies, the government, health plans and health care providers. This way, you can make better decisions and ultimately receive better care.

Managed Care – A system of health care delivery that is characterized by arrangements with selected providers, ongoing quality control and utilization review programs, and financial incentives for members to use providers and procedures covered by the plan.

Maximum Benefit – The maximum dollar amount that an insurance company will pay for claims, either for a specific procedure or service or during a specified period of time.

Medicaid – A state-administered health insurance program for low-income families and children, pregnant women, the elderly, people with disabilities, and, in some states, other adults. The federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their programs, so Medicaid varies state by state and may have a different name in your state.

Medical Loss Ratio (MLR) – A basic financial measurement used in the ACA to encourage health plans to provide value to enrollees. If an insurer uses 80 cents out of every premium dollar to pay its customers’ medical claims and activities that improve the quality of care, the company has an MLR of 80 percent. With an 80 percent MLR, the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs and agent commissions. The ACA sets minimum MLRs for different markets, as do some state laws.

Medically Necessary – A term used to describe the supplies and services needed to diagnose and treat a medical condition in accordance with the standards of good medical practice. Many health plans will only pay for treatment deemed medically necessary. For example, most plans will not cover elective cosmetic surgery.

Medicare – A federal health insurance program for people who are age 65 or older and for certain younger people with disabilities. It also covers people with End-stage Renal Disease (ERSD)—permanent kidney failure requiring dialysis or a transplant.

Medicare Part D – A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage. There are two ways to get Medicare prescription drug coverage: through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that includes drug coverage. These plans are offered by insurance companies and other private companies approved by Medicare.

Minimum Essential Coverage – The type of coverage an individual needs to have to meet the individual responsibility requirement under the ACA. This includes individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE and certain other coverage.

Open Enrollment Period – A period of time, usually but not always occurring once per year, when employees of companies and organizations may make changes to their health insurance and other benefit options. The term also applies to the annual period in which individuals may buy health insurance plans through the Marketplace.

Out-of-network – Typically refers to physicians, hospitals or other health care providers who do not contract with an insurance plan to provide services to its members. Depending on the insurance plan, expenses incurred for services provided by out-of-network providers might not be covered, or coverage may be less than for in-network providers.

Out-of-pocket Maximum (OOPM) – The total amount paid each year by the member for the deductible, coinsurance, copayments and other health care expenses, excluding the premium. After reaching the out-of-pocket maximum, the plan pays 100 percent of the allowable charges for covered services the rest of that calendar year.

Point-of-service Plan (POS) – A type of HMO that allows the patient to see either in-network or out-of-network providers. However, the patient pays more out of pocket when using an out-of-network provider.

Pre-admission Certification –Approval granted by a case manager or insurance company representative (usually a nurse) for a person to be admitted to a hospital or inpatient facility before admittance. The goal is to ensure that individuals are not exposed to inappropriate health care services, or services that are not medically necessary. Also called “precertification” or “pre-admission review.”

Pre-existing Condition – Any medical condition that was diagnosed or treated within a specified period immediately before a health insurance policy became effective. These conditions may not be covered for a specified period of time under the new policy.

Preferred Provider Organization (PPO) – A type of managed care plan in which health care providers and insurers agree to offer substantially discounted fees for covered health care services and to lower copays and deductibles for in-network services. The plan’s payment ratio (what your insurance company pays compared to what you pay) may be high—for example, it could be 90/10, with the insurance company paying 90 percent of medical costs and you paying 10 percent after the copay and deductible.

Premium – The amount of money charged by an insurance company for coverage.

Prescription Insurance – Insurance that helps pay for prescription drugs and medications. Prescription insurance is often offered as part a larger health insurance plan, though this is not always the case. Stand-alone individual prescription insurance may be available for people who are not offered prescription drug coverage or who have no health insurance. Eligibility for specific medications and the cost of insurance varies among health plans. Also known as drug coverage.

Preventive Care – Any medical checkup, test, immunization, or counseling service used to prevent chronic illnesses from occurring.

Primary Care Physician (PCP) – A health care professional who is responsible for monitoring an individual’s overall health care needs. Typically, a PCP serves as a gatekeeper for an individual’s medical care, referring him or her to specialists and admitting him or her to hospitals when needed.

Qualified Health Plan – An insurance plan that is certified by the Health Insurance Marketplace, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Marketplace in which it is sold.

Qualified Medical Expense – The costs attached to the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body.

Reasonable and Customary Charges – The commonly charged or prevailing fees for health services within a geographic area. If charges are higher than what an insurance carrier considers reasonable and customary, the carrier will not pay the full amount and instead will pay what is deemed appropriate for the particular service. The remaining charges are the responsibility of the patient.

Self-insured – A health benefits plan in which the employer is responsible for the cost of its employees’ health care. Typically, a third party provides administrative services for the plan to the employer group.

Summary of Benefits and Coverage (SBC) – An outline of a health insurance plan that allows somebody to evaluate costs and coverage and compare against other health plans.

TRICARE – A health care program for active-duty and retired uniformed services members and their families.

Vision Insurance – Insurance that covers specific eye care benefits defined in the policy. Vision insurance policies typically cover routine eye exams and other procedures, and provide specified dollar amounts or discounts for the purchase of eyeglasses and contact lenses. Some vision insurance policies also offer discounts on refractive surgery.

Waiting Period – A period of time in which your health plan does not provide coverage for a particular pre-existing condition.

Waiver – A rider or amendment to a policy that restricts benefits by excluding certain medical conditions from coverage.

Wellness Program – A program intended to improve and promote health and fitness, usually offered through the workplace, although insurance plans can offer them directly to their enrollees. The program allows your employer or plan to offer you premium discounts, cash rewards, gym memberships and other incentives to participate. Some examples of wellness programs include programs to help you stop smoking, diabetes management programs, weight loss programs and preventive health screenings.

Contact Consociate Health for more information.

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