Can Plan Members Control Costs?

One of the most common things that we run into is the question: “Can plan members help to control plan costs?” and furthermore, is there a conflict of interest?

With most things, there is a fair amount of debate. But with this question, my answer is explicitly “yes”.

In fact, most plan members are really looking for help from their employer because after all, they provide the plan and they are the ones that tell me that I have an increased premium next year.

Suffice to say, our industry is pretty loaded with various cost control methods and the plan member doesn’t even realize the full extent of their premium cost (taken directly out of paycheck). An example of these cost saving mechanisms is the restrictions that carriers place on the doctor networks or prescription formulas that you have access to.

While carriers and third party groups work to keep costs down (they do this so that they can stay competitive, by the way), there are a huge number of things that people can do on an individual level. And when you take into account that most companies are a fairly large group, minimal behavior change starts to add up to serious money saved.

First and foremost, the idea of “care intelligence” is the most important thing you’ll hear this year (it’s my term, cut me some slack). Before I get into it, think about this – who cares more about your outcome than you? Simply put, by understanding the way that the medical system works, and your role in it, your outcomes are significantly better. It’s a simple equation: The less you know the longer it takes to get better. The more you know the quicker you get better. And care costs money. A lot of money.

Its not that doctors can’t do their jobs, or that they are money hungry corporate fat cats. They just can’t do all things for all people all the time. You just need to know how to help the doctor figure out which of the 1,000 reasons you’ve got that headache.

Ultimately, it comes down to your level of comfort with each step in your treatment. While I can’t tell you how to get the best care on the planet, all in one 500 word essay, I can tell you this:

You have more power than you think you do

 

Is Telemedicine an ERISA Plan? And why this matters…. 

Noteworthy Definitions (boring industry jargon):

  • ERISA: The Employee Retirement Income Security Act of 1974: It is a federal law that sets minimum standards for most voluntary pension and health plans to protect the individual.
  • Telemedicine: Diagnosis or treatment by telephone or by mobile technology.

ERISA is designed to protect individual consumers, this much we know. There is a responsibility on the side of the firm offering each product to publish certain information made available to plan participants, and to the government.

So – the question on the mind is “does a telemedicine service need an ERISA plan?” The short answer… there is no short answer. But I will tell you a few things to make this whole process easier.

Firstly, employees can go and look for telemedicine companies on their own, and do so as much as they like. ERISA will only come into effect if this is a plan that is sponsored by the employer. Secondly, each group involved in answering this question has a different opinion. This includes telemedicine companies, health insurance brokers, and lawyers.  Each of these groups has a different horse in the race, so keep that in mind.

The most prominent opinion is this: “if a program offers or delivers medical services, then it is subject to ERISA”. If going off this advice, a written plan needs to be created. This can be a plan document and a summary plan description (known as an SPD to those in the “know”).

Reporting can be accomplished by one of 2 ways.  A separate ERISA plan can be created or it can be wrapped into the firm’s medical plan with a “wrapper document”. A wrapper document is the simplest method, but can be made more irritating if your group is fully insured.

Lastly – it is important to consider this – if you have wrapped your telemedicine plan under your health plan, then only plan members have access to the telemedicine program. If it has its own separate ERISA plan, then you can decide who will have access and let your employees run wild.

 

 

 

While I’d love to claim to be infallible in benefits speak, I am not. You should talk with your attorney and benefits advisor for proper adjudication. This is not a legal opinion!

 

 

 

 

 

About the Author

Bob Hanlon has been in the health insurance industry for over 30 years, so he has a few insider tips to share. Having founded and run his own agency, he realized the need for impactful communications to help people get more from their benefits. We all know about the complexities and frustrations that come with maintaining and affordable benefits plan and actually getting something out of it. In order to make this process easier for you, Bob has gone on to found Trig, a company that helps you do just that. If you want help, reach out to us. If not, check out our guide, we’re here to help.