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.
