Just when you’re sure you’ve thought of everything . . . you wake up in the middle of the night, remembering the one thing that, maybe, no one considered.

At HealthComp, we work with brokers daily on a broad variety of challenges, questions and problems to help them develop the plan designs that will meet the needs of their clients. With plan design season upon us, here are seven questions that we’ve identified for consideration in the plan development process, so everyone can rest easy.

Consistency is Key

1. Are there inconsistencies between plan documents and network contracts in terms of what is covered?
   If there are differences between these two documents, it’s possible that the provider network will submit bills for services that the plan document does not allow to be paid.
   
   For example, the plan may require a pre-certification before an MRI is performed, but the network does not have that requirement in its contract.  The provider refuses to obtain the pre-certification because its contract does not require it. However, the plan can’t pay the claim without it. The member is stuck in the middle.
   
   The solution is to check for these inconsistencies and to remedy them in advance to avoid financial losses and member distress.
   
2. Are the provisions for appeals in your network contract in sync with your plan document?
   Sometimes, network contracts may have claim submission or appeal submission deadlines that exceed the limits listed in the plan document. This can lead to significant financial losses for employers due to stop-loss denials. To avoid this, plans should be structured so that their deadlines align with their contractual deadlines.
   
   Here’s an example: An employer’s network allowed providers four years to file an appeal on a claim that is priced through a plan. Not only was that beyond the deadline under the plan document, but by the time the late appeal came in, the stop-loss policy had ended, so it was no longer eligible for reimbursement.
   
   The inconsistency between the plan document and the appeals process in the network contracts caused a significant loss to the plan sponsor.
   
3. Are the provisions in the employee handbook in sync with the plan document?
   If there are gaps, the plan could experience a surprising and unwelcome loss. Let’s suppose the employee handbook offers eight weeks of approved medical leave in addition to that required by FMLA and other bodies. The employer’s leave policy should be referenced in the plan document in order for the employee to remain covered for medical benefits during that time.
   
   If it is not in the plan document, significant and costly claims may be incurred that will not be paid by the stop loss carrier.  There is no proof that the employee was an employee at that time, and therefore, they are considered to be ineligible for benefits.

Always Keep Members in Mind

1. Does your plan design have the flexibility to enable members to get all the services they need?
   Plan design may not allow for the flexibility to cover what the member needs, or to cover a course of action that is actually a lower overall cost to the plan.
   
   For example, physical therapy may be limited to a certain number of visits, but in some situations adding more visits will avoid a much more costly treatment, such as a surgery. Or, more home health visits could avoid the need for a patient to go back into a skilled nursing facility.
   
   Including an “alternative benefit” provision in the plan allows for this flexibility which is best for the member and best for the plan.
   
2. Are members likely to be confused and frustrated by too many variations in plan design?
   The more complicated the plan design, the greater the likelihood that the member will become confused and dissatisfied. Also, complicated plan designs are more expensive to administer than are simpler approaches. Multiple levels of co-pays and deductibles may be more trouble than they are worth. Having one level of co-pay and deductible for office visits and one for inpatient care makes it easier on everyone.
   
   Conversely, sometimes a more complicated plan design may be necessary to meet the goals of the plan sponsor. For example, a firm may have many subsidiaries, and multiple classifications of employees and desire to offer different options to these groups. Other organizations offer a basic plan and allow employees to pay the differential for a richer plan. The sponsor may want to offer coverage for services like fertility treatments, but at a higher co-pay or deductible than other benefits. With multiple benefit levels, it’s even more important to write member communications that are clear and understandable.
3. Are members likely to be saddled with larger co-pays or balanced billing debt because they don’t know how to verify that a provider is in their network?
   When members do not ask the right questions of a provider, too often, the answer to this question can be “yes.” That’s because members don’t realize that the question “do you accept my plan?” does not mean the provider is in the network.
   
   Few situations are as upsetting to a member as receiving unexpected bills for services they thought were covered.
   
   Here’s an example of how easily this can occur. A doctor refers a patient to an outpatient surgery center, in which the physician might have a financial interest. The member asks the facility, “Do you accept my plan?” and the answer is “Yes”. However, the center is not in the network, which makes the cost of the surgery considerably more than it would be in a hospital, and the member is shocked to be charged thousands of dollars to cover out-of-network charges for a service that is already priced much higher than market.
   
   Similar situations can happen with urgent care and with laboratory costs. When any of these scenarios occur, it’s understandable that members are upset and angry and blame the plan.
   
   The solution is a member engagement challenge – teaching members to ask “Are you in my plan’s network?” instead of “Do you accept my plan?” This education, while not mandated in the plan design per se, can be accomplished through member materials, EOB statements, signage in the workplace and in telephonic discussions with members. These communications can and should begin as soon as possible, preferably during open enrollment, along with other communications about deductibles and co-pays.
   
   
4. Does the plan cover a population with unique regulatory and legislative issues that impact how their coverage should be designed?
   An example is the multiple complexities in covering Native American tribes. In general, the tribes follow Federal plan guidelines but may have options to pay Medicare rates if there is a clinic on-site at the reservation. Also, specific guidelines apply to tribal members but not to non-tribal members who might be working in a casino. Specialists in Native American coverage issues can be brought in to ensure that all regulatory requirements are congruent with the plan design.

HealthComp’s experts are available to collaborate on these points and others to ensure that pitfalls are avoided; plans are streamlined for member engagement and understanding; and plan sponsor needs are met.