Presbyterian

Health Plan, Inc.

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Home|Employers & Producers|Forms and Resources|Administrative Services Only

Administrative Service Only (ASO) / Self-Funded Insurance Plan

 

Presbyterian Health Plan, Inc. can provide Administrative Services Only for employer groups with typically 100 or more employees who decide to fund their own healthcare benefit plan. Self-funded benefit plans allow employers to take control of their company's employee healthcare coverage, both in the design and funding of the plan.

What is a self-funded health insurance plan?

In a "self-funded" or "self-insured" group health plan, the employer assumes the financial risk for providing healthcare benefits to its employees instead of an insurance carrier. Self-funded groups pay for employee medical costs as they are incurred instead of paying a fixed premium to an insurance carrier (known as fully insured coverage). Typically, a self-insured employer will set up a special trust fund to earmark money (corporate and employee contributions) to pay claims as they are incurred. The employer evaluates the purchase of stop loss insurance to protect the plan from catastrophic losses. The employer contracts with a third-party administrator to administer the benefits.

Employers who choose self-funding can achieve cost savings through:

  • State premium taxes, which usually run from 2% to 6% of premium in fully-insured programs, do not apply to self-funded programs.
  • Investment earnings, which accrue (usually tax-free) in the employer-established health trust, are available to fund plan expenses.
  • Potential freedom from costly state-mandated benefits.
  • Plan costs are based on your group claims experience, not pooled with any other groups.

Employers can also gain control

With self-funding, you can develop a plan of benefits tailored to suit the needs of your employees. Additionally, you have complete control and knowledge of where and how contributions are distributed.

Presbyterian provides local servicing of your self-funded insurance plan

Presbyterian is locally owned and operated - which means all member services, claims processing and enrollment processing are conveniently coordinated here in New Mexico by our local service team.

Presbyterian offers a full range of administrative services for self-funded plans including:

  • Plan Document Preparation
  • Benefit Plan Design
  • Claims Processing Services
  • Comprehensive Network Access
  • Utilization Management
  • Disease Management
  • Case Management
  • Member Services
  • Marketing Services
  • Finance Information Technology Support
  • Materials Preparation and Provision
  • And much more

To discuss the advantages of self-funding and Presbyterian's Administrative Services, consult with the Presbyterian Sales department:

Minimum Requirements

A Group must typically have a minimum of 100 employees enrolled to be eligible for an ASO arrangement.

Stop Loss Coverage

Aggregate and Specific Stop Loss coverage can be provided through multiple insurance carriers.

Specific

This coverage is for medical only expenses. Dental, Vision, weekly income, capitation and any administrative fees are not eligible under the Specific. Minimum and maximum guidelines for appropriate Specific Deductible levels are based on expected claims and the size of the group. Contract types include:

  • Incurred
  • Incurred and Paid
  • Incurred in 12 and paid in 15 Paid
  • Incurred and paid with Run-In

Aggregate

Aggregate coverage can be provided to cap the employer's overall liability for eligible self-funded claims in a given contract period. This coverage addresses the accumulation of expenses on all individuals as opposed to high expenses for a particular individual.

Administrative Fees

Fees can be calculated either on a Per Member Per Month (PMPM) or Per Employee Per Month (PEPM) basis. Fees are determined by the size of group as well as administrative services requested.

Description of Services

Claims Processing:

  • Processing and adjudication of all participants' claims from in-plan and out-of-plan providers:
  • Coordination of benefits
  • Subrogation
  • Submission of explanation of benefits to participants
  • Designated claims unit dedicated to self-funded benefit plans

Network Access

A full panel of physicians, hospital and providers that have been contracted with Presbyterian Health Plan at a negotiated fee schedule. Includes all forms of network management and maintenance.

Utilization/Medical Management

  • Referrals (if appropriate)
  • Preauthorizations
  • Preadmission review
  • Concurrent review
  • Case management services

Disease Management

Programs focusing on diseases that are more prevalent in our state and our health plan's population than the national average. Some examples of these are:

  • Diabetes
  • Asthma
  • Coronary artery disease

Member Services

Member helpline accessed via toll-free telephone number to address member inquiries. Designated member services unit dedicated to self-funded benefit plans.

Account Services

Designated account service providing day-to-day service including but not limited to:

  • Assistance with open-enrollment
  • Benefit education
  • Communication to employees
  • General service issues
  • Report analysis
  • Renewal issues

MIS Support

Standard data reports provided on a periodic basis and support for EDT transactions and web based services.

Web-Based Services

Access to myPRES which includes the ability for members to:

  • Check the status of claims and authorizations
  • Change Primary Care Physician (if applicable)
  • Update member information (if allowable)
  • Add dependents (if allowable)
  • Review the Summary Plan Document (SPD) online
  • Find PHCS/Multiplan providers for services received out-of-state
  • Find a provider

Employers are able to check:

  • Eligibility
  • Review a member's demographic information
  • Review the Summary Plan Document (SPD) online
  • Find PHCS/Multiplan providers for services received out-of-state
  • Find a provider
  • Add/remove dependents

Materials Provided

  • ID cards
  • Claim forms
  • Help with Summary Plan
  • Document creation/revision
  • Enrollment forms
  • Announcement letters

Request for Quote

The following items are needed so that a complete Stop Loss and Administrative quote can be generated:

  • Name, Address and Zip Code of Group
  • Effective Date
  • Date quotation is requested
  • SIC or NAICS code (if not available, industry description)
  • Census by gender, DOB or age, Single/family contract counts. Can be summarized in 5 year increments by first three digits of zip code if multiple locations.
  • Current Plan Benefits and Proposed Plan Benefits (if different)
  • Current/Proposed Stop Loss Specific Deductible and Contract Basis
  • Current renewal rates (if available)
  • Known current and potential shock claims and adverse health conditions
  • Claims experience and contract counts by month for minimum of 12 months, preferably at least 2 years.