Paradigm Health Plans

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The Paradigm Health Plans Solution

[email protected]

mailto:[email protected]

http://www.paradigmhealthplans.org/


The Paradigm Position

• Formed in 2007, Paradigm Health Plans® is an industry

leader in self-funded plans, partnering with businesses to

empower employees to actively manage their health care

costs through our Member Advantage Program

• 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 US strategic cities first

quarter 2016

• Paradigm’s Member Advantage ProgramSM allows for the

Employer and their Employee’s to reduce or eliminate their

out-of-pocket expenses

• Our Lifestyle-for-Life Program® Health Management

Program includes 38 panel BioMetric Screenings provided on

site


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 Plan’s 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


The Paradigm Service Model

Reinsurer/Stop Loss Carriers:

AIG

FSL

Munich RE

Fairmont Specialty(Crumb and Forrester)

Standard Security

Lifestyle-for-Life

And Health Management

TPAFor Processing

& Billing

Auxiant

Leased Network

CIGNA PPO

AETNA PPO & OA

Anthem BCBS PPO


Plan Designs that Work

• Comprehensive EPO/Health Plans

• 30 FTE and Above

• Wage Parity/Living Wage Plans

• Supplemental for Living Wage

• Minimum Essential Value (MEV)

• Minimum Essential Coverage (MEC)


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


Member Advantage Programs Find Out How We MAP the Gap

in Healthcare Expectations

• Research and Present the Quality 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 procedures such 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- that will:


Self-Funded Plan Advantages

• Level Funding: Make 12 payments and you owe nothing else

• True 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

Determine your maximum annual costs upfront - guaranteed!


Self-Funded Opportunity Grows

The Affordable Care Act

Increases Interest in Self-Funded Plans:

Health Plans once offered to Management and salaried employees only 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

were expecting to grow their self-funding portfolios in 2015


Drivers for Self-Funded Increases

Health Insurance Premiums are Increasing at an unsustainable rate

• Employees pay 89% more for family health care 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 that 3.5%


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 and results 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 that utilize the MAP Program significantly reduce their out-of-pocket

expenses and can spend money on what they love- not healthcare they need!


Self-Funded vs. Fully Insured

Most Frequently Asked Questions

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 saving!

GUARANTEED!


Controlling Clients and Members Costs without Disruption


Members will have access to the Best PPO Networks Available


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 negotiating all claims above $5k


Paradigm Health Management Program and True ROI

• 20.7% lower medical spending compared to companies not using the

Lifestyle-For-Life® program

• Reduces medical spend vs. forecast by up to $1,332 per member per year

• 81% of members voluntarily participate in our program and 81% of those Members

achieve measurable improvements in their lifestyle related goals

• 6-9% Annual savings on Claims Cost

Our Lifestyle-for-Life® Program Health Management Program powered by Interactive Health™


Premier Provider Program

• Premier Providers provide 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%

• Premier Providers remove Facility charges and outpatient hospital excess

claims cost.


Questions?

www.paradigmhealthplans.org

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http://www.paradigmhealthplans.org/

Date post:	16-Aug-2015
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