888.303.0034 | www.paradigmhealthplans.org Page | 1 The Paradigm Health Plans Solution Presented to: (ABC Company) [email protected] www.paradigmhealthplans.org
888.303.0034 | www.paradigmhealthplans.org Page | 1
The Paradigm Health Plans Solution Presented to: (ABC Company)
[email protected] www.paradigmhealthplans.org
888.303.0034 | www.paradigmhealthplans.org Page | 2
The Paradigm Position• Formed in 2007, Paradigm Health Plans, LLC® is a wholly-
owned subsidiary of Paradigm Health Holdings, an industry leader in self-funded plans, partnering with businesses to empower employees to actively manage their healthcare costs through our Member Advantage ProgramSM
• Since 2013, Paradigm has seen an increase in new group self-funded sales and members of more than 180% over a two-year period
• Paradigm has offices in New Hampshire and Long Island, New York, and is expanding in four strategic U.S. cities in third-quarter 2016
• Paradigm’s Member Advantage ProgramSM allows for the Employer and their Employees to reduce or eliminate their out-of-pocket expenses
• Our Lifestyle-for-Life® Health Management Program includes Biometric Screenings of up to 38-panels provided on-site
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The Paradigm PositionThe healthcare market has been evolving and changing for several years, and it will continue to become more complex
Option 1:Business as Usual• Brokers continue to be subject to
whatever regulatory changes occur
• Inherit increased costs due to regulatory changes
• Lack of control and unpredictable costs for brokers and their clients
Option 2:Partner with Paradigm• Brokers and Clients can become
pro-active and regain control of the quality, access and cost of their healthcare plan
• Explore Paradigm Health Plans’ Self-Funding Solutions and find out how our Member Advantage Program℠ (MAP) saves Clients and their Employees time and money!
• Start giving your Clients accurate Rate Renewal Pricing
OR
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The Paradigm Service Model
Reinsurer/Stop-Loss Carriers:
AIGFSL
Munich REFairmont Specialty
(Crumb and Forrester)Standard Security
Lifestyle-for-Life®
And Health Management
TPAFor Processing
& Billing
Leased NetworkCIGNA PPO
AETNA PPO & OAAnthem BCBS
PPO
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Plan Designs that Work
• Comprehensive EPO and PPO Health Plans
• 30 FTE and Above
• Wage Parity/Living Wage Plans
• Supplemental for Living Wage
• Minimum Value (MV)
• Minimum Essential Coverage (MEC)
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Workforce/Ancillary Coverage
• Dental
• Vision
• Short- and Long- Term Disability
• Critical Illness/AD and D/Group Life
• Pharmacy Benefit Management
• Telehealth, Video, Skype Conferencing using 1-800MD
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The Member Advantage ProgramMap the Gap: Closing the GAP in your Healthcare Plan
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MAP The GAP: Resetting Member Expectations
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MAP The GAP: Resetting Member Expectations
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How MAP Works
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MAP The GAP: Services
• Research and Present the Qualifications of providers to Members
• Review Benefits Prior to Plan Year Commencement
• Reduce or Eliminate Member OOP Expenses
• Locate in-network providers
• Schedule doctor visits for the family each year
• Provide quality and cost information on providers and proceduressuch as labs & diagnostics and surgeries
• Order RX/medications for members - no paperwork!
• Resolve tough billing issues
• Explain the summary of benefits
Each Enrolled Member Is Assigned A Dedicated MAP Who Will:
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MAP The GAP: Program Results
Access to the highest-quality medical services that reduce or eliminate the co-pay, co-insurance or deductible costs for the members
Reduce RX costs by 18% to 22%
Reduce Complex Imaging costs by 61%
Reduce Lab & Diagnostics costs by 76%
Remove Facility charges and outpatient hospital excess claims cost.
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Non-MAP Users vs.
Paradigm MAP Users
Physician Visit
Urgent Care
Retail Clinic
Emergency Room
$0 $100 $200 $300 $400 $500 $600
National Average Member OOP Expense
USING THE
MAP PROGRAM,
THESE EXPENSES CAN BE
REDUCED OR ELIMINATED
ENTIRELY
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Self-Funded Plan Advantages• Level-Funding: Make 12 payments and you owe nothing else
• 115% corridor funded
• 125% corridor funded
• Self-Funded Options
• 100% of unspent claims surplus is returned to Client!
• Access to Tier 1 PPO networks, such as CIGNA, Anthem and Aetna
• Guaranteed Max Rate Cap Increase for 3 renewal cycles (Paradigm Exclusive!)
• Easy Fund: Our New Aggregate Management Program
• Savings Partners Program: Less up-front costs
Determine your maximum annual costs upfront!
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Self-Funded Opportunity GrowsThe Affordable Care Act
Increases Interest in Self-Funded Plans:
Health Plans once offered only to Management and salaried employees must be offered to the balance of the workforce, scaling up the employers count of employees
As a result, small groups become large groups, and become excellent candidates for self-funded plans
82% of Health Executives expressed a growing interest in self-funding their group health insurance plans
70% of health organizations expected to grow their self-funding portfolios in 2015
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Drivers for Self-Funded Increases
Health Insurance Premiums are Increasing at an unsustainable rate:
• Employees pay 89% more for family healthcare premiums then they did a decade ago.
• In 2013, premiums rose 4%, but that was still twice the rate of wages.
• According to a 2011 Department of Labor report, fully-insured premiums increased by $808 and self-funded premiums increased by $248.
Paradigm Health Plans’ average premium renewal
increase for clients is less than 3.5%
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Drivers for Self-Funding: Health Industry Consolidation
• Health Industry consolidation has increased more than 50% since 2009 - with more consolidation in 2014
• Higher prices are sure to follow in some markets
• Hospital Mergers can lead to price increases of up to 20%
• These prices are especially acute in markets with one dominant health system
• Over half of hospitals plan to acquire physician practices in 2014 compared to 44% in 2012
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Paradigm Health Plans Clients vs.
National Average Medical Cost Trends
Average Medical Cost Trend Nationally
Paradigm Client Average Renewal Increase
0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00%
Compare the Difference with Paradigm Health Plans!
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Self-Funded Employers: Deeper Discounts using Paradigm Health Plans
• Self-funded plans still meet ACA Guidelines and provide comprehensive benefits
• Employers gain control over their Network selections without limitations in provider choices (No Narrow Networks or Large Disruption!)
• Paradigm’s Lifestyle-for-Life® Program allows for cost containment with incorporated biometric screenings, health assessments, disease and care management resulting in a 6-9% savings on claims costs!
• Paradigm’s Member Advantage Program (MAP) embedded in most Paradigm Health Plans allows for Employers to contain costs when they encourage Members to utilize the programs
• Members who utilize the MAP Program significantly reduce their out-of-pocket expenses and can spend money on what they love – not on the healthcare they need!
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Self-Funded vs. Fully-Insured
1. What if claims exceed your monthly payment?• For Fully-Insured Groups, the Insurance Company pays the claims
• For Self-Funded Groups, the Stop-Loss carrier pays the claims
2. What if claims are less than your monthly payment?• For Fully-Insured Groups, the carrier keeps the difference
• For Self-Funded Groups, the Employer keeps 100% of the savings!
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Controlling Costs without Disruption
LEVEL ONEMajor PPO Providers | Highest Quality Of Doctors & Hospitals Reduces Medical Claim Costs |
Aetna And CignaLEVEL TWO
Paradigm Premier Provider Network | Highest Quality
Providers For Lab & Diagnostics, Prescription Drug/RX And
Complex/Advanced Imaging | Reduces Claim Costs
LEVEL THREEPPO Wrap Network | Plan
Design Rewarding Members For Proper Plan Utilization | Member Advantage Professional Service
For Member Education And Convenience | Negotiate All
Claims Above 5k | Use Our Out-of-network Shared
Savings Programs | Fraud Management System |
Subrogation Of Non-plan Responsible Claims
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Members Will Have Access to the Best PPO Networks Available
More than 200 Networks are available to Paradigm Health Plan Clients!
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To contain costs, you must know where they come from
74% of healthcare costs are due to lifestyle-related conditions, and are therefore preventable
52-61% of all claims come from these standardized services: Rx, Complex Imaging, Urgent Care, Preventative, Labs & Diagnostics
32-37% of all claims are for Inpatient or Surgical procedures at hospitals that charge more, simply because they can
Reduce costs by auditing all claims above $5k
On average in 2012-2014, Paradigm Health Plans Clients saved more than $14K annually
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Lifestyle-for-Life® Health Management Program
• Provides a dedicated Program Manager: We do the work for you!
• Biometric screening of up to 38 panels: identify hard-to-treat diseases before they progress!
• Health Assessment
• Health Evaluation
• Healthy Activities
• Workplace Wellness Champion
• 20.7% lower medical spending compared to companies not using the Lifestyle-For-Life® program
Results in a 6-9% Annual savings on Claims Cost
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Questions?
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