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Designing Your Group Captive Plan to Cut Costs Your Way

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Highlights

 

-A strong summary plan description (SPD) explains your insurance plan, including eligibility, to your employees.

 

-Roundstone allows you to customize your SPD to include cost-containment strategies.

 

-Roundstone offers the flexibility to choose your own pharmaceutical benefits managers and third-party administrators.

 


 

Affordable health insurance is often out of reach for many small to midsize businesses and their employees. With the average family’s insurance premiums rising faster than inflation and wages, many small business employers cannot shoulder the cost, passing it along to their employees through higher premiums, deductibles, and copays, leading many workers to take home less every year as wages stagnate.

 

Group captive insurance from Roundstone Insurance is an excellent option for affordable small to midsize business health insurance. We recognize that your company is unique, so we provide the flexibility to tailor a plan specific to the needs of your business and employees.

 

Here’s how we’ll help you do it.

 

Start With a Strong Summary Plan Description

 

A Summary Plan Description (SPD) is a document given to employees to explain important facts related to their health insurance benefits. Required by the Employee Retirement Income Security Act of 1974, (ERISA), an SPD ensures transparency and accountability, preventing retirement and healthcare benefit administrators from violating employees’ best interest.

 

The SPD should be written in plain language with minimal legal and technical jargon and should explain or identify the following:

 

-The employer’s name and address

-The plan administrator’s name and contact information

-The plan’s benefits and who is eligible for them (employee, spouse, dependents, etc.)

-How the plan works

-When the employee becomes eligible for the plan

-How benefits are calculated and paid, including co-insurance, co-pays, deductibles & annual limits

-How to claim benefits

-When benefits become vested

-HIPAA rights

-ERISA disclosures

-Grievance and appeals procedures

-Participants’ rights and obligations

-COBRA Continuation Coverage

 

Employers must give new employees their SPD within 90 days of becoming eligible for the coverage. If the SPD is changed to reduce coverage for the employee, the employer must provide a revised SPD within 60 days. If the changes do not reduce coverage, the employer has 210 days to share the updated SPD.

 

The SPD helps employers make smart decisions about the coverage they offer, saving their company money and better managing their employees’ healthcare needs.

 

The Roundstone Plan Document

Crafted by a team of claims adjusters, clinicians, and attorneys, the Roundstone SPD is explicitly designed to manage and minimize your healthcare costs. We carefully create our documents to be employer-friendly. The plan document includes clearly defined terms to make understanding coverage easier for your employees and eliminating potentially costly misunderstandings.

 

Decide Who is Eligible

 

Eligibility is one of the most critical areas of the SPD. The wording must be clear, concise, and precise to avoid future complications. Our SPD writers are experts in the medical, insurance, and legal fields, so you can count on it to be precisely worded to protect you.

 

The eligibility section of the SPD should state who is eligible under the plan to receive benefits, when they are eligible, and how long coverage lasts when an employee leaves the company. The Roundstone SPD defines standard terms like spouse, domestic partner, child, and dependent so employees can better understand their family members’ eligibility.

 

Choose Your Third-Party Administrator

 

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Your third-party administrator (TPA) works with you to develop and design your personalized SPD each year and any amendments made to it throughout the year. The TPA also works with claims management to ensure accurate processing of claims.

 

At Roundstone, we let you choose the TPA you use. Our in-house TPA is Bywater, and we highly recommend them. But if there is someone specific you wish to work with, we will work to get them vetted and approved for your use.

 

When looking for a TPA, we recommend you consider their area of focus, particularly when it comes to company size. A TPA who usually works with companies with more than 1,000 employees may not be as effective for a company with 50 employees.

 

Employers should also investigate a TPA’s vendor flexibility. You want to make sure they work with the PBM you’ve chosen  as well as any cost-containment vendors you wish to include in your SPD.

 

Choose Your Pharmaceutical Benefits Manager

 

Pharmaceutical Benefits Managers (PBMs) are an important component of a healthcare plan. Even if you currently have a fully insured plan, you have a PBM; you just didn’t get to pick them, which means they are working on behalf of the insurance companies, not you.

 

A PBM works with prescription drug manufacturers, pharmacies, and wholesalers to gain access to medications for your employees.

 

There are three types of PBMS:

 

Traditional PBMs: These generally work for the insurance companies and keep any savings they negotiate as profit.

 

Transparent PBMs: This type of PBM has an open fee structure and a transparent contract, so it’s easy to see where your money is going.

 

Pass-through PBMs: These PBMs are paid via administrative fees rather than a cut of the savings they negotiate. They pass on 100% of any savings from manufacturer’s coupons and rebate programs straight to you.

 

Roundstone recommends all employers use transparent and pass-through PBMs because they provide the most benefit to you.

 

The right PBM reduces prescription drug costs while offering your employees better medications through:

 

-Prescription delivery services

-Price negotiation

-Co-pay assistance programs

-Mail-order pharmacies

-Access to specialty pharmacies and their networks for high-cost prescriptions

-Generic options that provide the same benefits but cost less

-Passing pharmaceutical company rebates through you rather than the fully insured insurance carrier (as with traditional PBMs).

 

Choose Your Cost Containment Strategies

 

coins in a glass container

 

To customize your Roundstone SPD to meet the needs of your company, you can add cost containment programs and vendors allow you to address your spending just as you would any other business expense.

 

Use the CSI Dashboard for Claims Transparency

Roundstone focuses on helping you save by providing transparent data about your employees while adhering to HIPAA privacy guidelines. Unlike fully insured insurance carriers, we believe in full disclosure and that your claims data belongs to you.

 

As a Roundstone group captive plan member, you will have access to our Cost Savings Investigators (CSI Team) and the CSI Dashboard. The Dashboard gives you access to all of your plan’s claims data. You’ll be able to see how much your workforce has spent for healthcare visits, medical procedures, prescriptions, and more.

 

Our CSI Team will shoulder the burden of interpreting your data and researching cost-containment strategies based on their findings. The CSI Team’s attention to detail ensures you can trust that their recommendations are suitable for your employees’ needs based on their claims usage.

 

For example, if our CSI Team finds that you are spending more on specialty care, prescription drugs, or emergency department visits than national benchmarks, they will recommend solutions designed specifically for your company to bring those costs down. And unlike a fully insured plan, in many cases you won’t need to wait until your next renewal to implement a new savings plan or program.

 

Employ Population Health Management Strategies

Population health management strategies seek to improve health outcomes for your employees, which can increase savings for your company.

 

You can implement patient engagement strategies as well as care coordination incentives and penalties to assist employees with managing any chronic diseases (e.g., diabetes and COPD). You can encourage overall well-being by encouraging enrolled employees to participate in wellness and preventative care initiatives such as weight-loss or smoking-cessation programs.

 

By incorporating population health management into your SPD, you help your employees improve their overall health. Their odds of developing more severe conditions in the future, such as heart disease due to obesity, decrease.

 

When employees participate in wellness and preventive initiatives, they discover health issues early when they’re easier and less costly to treat. This reduces costly emergency department visits and hospital stays down the road.

 

By offering services such as telehealth, biometric screenings, and diabetes management, you save money because your employees won’t be filing as many hospital-related claims. Plus, happy, healthy employees are a more productive workforce.

 

Roundstone can work with you to get a vendor approved for your new plan if you already have population health management features that you’d like to offer your employees. And our CSI Team works hard to help providers design and implement programs that work for your particular population.

 

With Roundstone, You Have Choices

 

At Roundstone, we believe affordable health insurance should be affordable for everyone, especially small to midsize businesses. We’ve found the best way to do that is to give you options.

 

You choose your TPA and PBM. You decide what and whom your plan will cover. And you have complete access to your claims data, allowing you to build cost-containment strategies into your plan.

 

Group captive insurance from Roundstone offers the freedom and flexibility to offer affordable, high-quality healthcare benefits to your employees, your way.

 

Request a proposal and benchmark review today to find out how Roundstone Insurance can help you take control of your healthcare spending.

 

Learn why you have few cost-controlling options with fully insured insurance carriers. 

 

learn the secret behind your group health insurance plan

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