Health Plan Design

Plan Design Ideas: How to save members from surprise bills

New technologies and approaches to care have made plan design choices more complicated than ever before. But ignoring your options may lead to serious consequences.

From member confusion to limited care access to surprise bills—top benefits leaders are increasingly working with their partners to evaluate new and interesting plan design ideas that address common health plan issues.

We’ve compiled a list of some of the most innovative options out there today in our guide, 8 Big Health Plan Ideas. Check out some of the ideas below—each with their own pros and cons.

03. Don’t penalize members with surprise bills

While members on fully-insured plans are often protected by state laws that prohibit out-of-network emergency rooms and ambulances from balance billing, members on self-funded plans are exposed. This can also be a problem when in-network facilities contract with out-of-network providers (like anesthesiologists) and services (like labs).

Solution? If your member goes to an out-of-network ER or ambulance and she is balance billed, structure your plan to cover that additional cost. Also, if a member goes to an in-network facility but is then exposed to out-of-network services, be willing to apply in-network cost-sharing rules across all services related to that visit.

PROS

  • Provides protection for difficult situations in which members have no decision-making power over network status
  • Allows your self-funded plan to absorb the expense of a large, surprise bill (rounding error to your total spending) rather than subject members to major financial strain (and potential bankruptcy)

CONS

  • If employers are willing to absorb more of the cost, there is a high likelihood that total medical spend will increase
  • Theoretically, providers could game the system by charging higher out-of-network fees, knowing that the patient’s employer will pick up more of the cost

04. Question if prior auths are working

Prior authorizations (PAs) can be frustrating. They’re a source of considerable member friction, interfere with prescribed member care plans, and do not clearly provide any actual value to employers.

Solution? Be willing to selectively turn off PAs where they aren’t essential, or at least reduce the penalties associated with PA non-compliance

PROS

  • Eliminates a major source of member friction
  • Makes it easier for members to adhere to their prescribed care plans

CONS

  • Eliminates a safeguard against inappropriate care
  • Potentially increases plan cost

Want more bold health plan ideas? Download our whitepaper, 8 Big Health Plan Ideas, to learn more and see if it’s time to make changes to your strategy.

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Trace3 DataSafe
eBay Red Bull Activision Blizzard Zendesk Counsyl Trace3 DataSafe