Health Advisor

Bundled vs. Unbundled Self-Funding

Self-Funded Benefit Plan Components

Reinsurance Carrier: The employer purchases reinsurance to protect themselves from large individual claims or a high volume of small claims. 

Claim Processor: The claim processor adjudicates and pays the medical claims for the plan. They also coordinate the administration with the other parts of the benefit plan to ensure the medical claims are processed according to the plan document. The administrator also obtains provider discounts on large claims, seeks reimbursement from the reinsurance carrier, completes legal documents, and other administration functions. 

Prescription Benefit Manager: A Prescription Benefit Manager (PBM) maintains a network of pharmacies to provide prescriptions to plan participants. The PBM obtains favorable pricing from their member pharmacies, saving the plan prescription claim expenses. The PBM also administers all other aspects of the prescription benefit.

Network: The network is a group of doctors that have contracted to provide services to members at a discounted rate. The plan saves money when members use member physicians, so the medical plan usually includes incentives for members to use the network doctors. 

Care Management: Care management includes large case management and disease management. These services are provided by medical professionals to intervene and assist in the management of catastrophic illnesses, helping to provide the best and most cost-effective care possible.

Wellness: A properly implemented, clinically-based wellness program helps plan participants live healthy lives, improving productivity and minimizing medical claims.