Under review
Reprints
Questions for mid-market employers' request for proposals in reviewing their health plans:
• Describe all health plan designs including coverage descriptions, copayments, deductibles and premiums.
• Describe care and utilization management services including wellness, health promotion and prevention, chronic disease management, case review, second-opinion and pharmacy benefit management*.
• Describe claims payment functions, including how often and how providers are paid (electronically or by check) and when explanation of benefits are produced and sent to plan members.
• Describe member support services, including automated enrollment; toll-free call centers and consumer engagement tools to compare provider cost/quality, estimate/budget cost of care; provide member outreach to encourage participation in behavior change and disease management programs; and formulary management*. How can members access customer service — via the Internet, telephone or both?
• Provide a detailed description of the medical appeals process, including typical turnaround time for decisions; confirm that appeals process complies with the health care reform law; and indicate any costs associated with the appeals process.
• Provide complete provider directories including hospitals, doctors, labs, imaging centers, retail pharmacies and any other ancillary providers. How are directories accessed — via the Internet or in print? How often are directories updated? Provide provider turnover rates.
• Explain how the plan measures cost and quality for primary care providers, specialists and facilities.
• Confirm willingness to fund and submit to an annual claims audit conducted by an independent third party.
*Pertains only to health plans that also offer pharmacy benefit management services.
Read Next
-
Employers should consider overall benefits when choosing health insurers
When Jan Strompf and Jerry Friedlander formed Janjer Enterprises Inc. in 1981, they decided to offer a health benefits package that would engender loyalty among employees of the company, which owns and operates 29 Popeyes Louisiana Kitchen franchises around Washington, D.C.
