Lesson 6 Flashcards
6.1.1 List three primary activities involves in administering group benefits
1) Determining the appropriate administrative approach
2) Performing admin activities
3) Evaluating the overall program and specific benefits
6.1.2 Describe the factors that influence which of the three main administration approaches will be available to a plan sponsor
3 main approaches
- self-administration
- insurer administration
- TPA
Factors include:
- in house capabilities
- number of lives insured
6.1.3 Explain the responsibilities a plan sponsor has in the claims process under an insured plan that is self administered
The plan sponsor provides member eligibility data to the insurer or TPA so it can adjudicate claims.
Certification or validation for claims of eligibility for life insurance, AD&D and LTD is done by the plan sponsor
6.1.4 Contrast the insurer’s role in a self-insured plan with an ASO vs an insurer administration arrangement
These are virtually the same procedures.
The key difference is that for self-Insured with an ASO the sponsor is liable for payment.
6.1.5 Discuss considerations in the outsourcing of claims processing to a TPA
Claims processing is usually only outsourced when the plan is large.
TPA covers in house dental, health & WI/STD claims processing and benefit capabilities.
The TPA is paid a fee for services. For self insured plans there is a billing arrangement set up to make sure there are sufficient fund.
Typically there are regular reports with respect to account balance and funds withdrawn.
6.1.6 List 5 things that are part of a plan sponsor’s administrative role under an insured self administered arrangement
1) Maintain member records
2) Provide plan member eligibility data to insurer or TPA for health, dental & WI/STD processing
3) Certify eligibility for life insurance, AD&D and LTD
4) Prepare monthly premium billings for insured plans
5) Handel all plan member inquiries regarding eligibility
6.1.7 Identify types of plan member data provided by the plan sponsor to the insurer or TPA for health, dental and WI/STD (12)
1) Name of plan member & Dependents
2) Sex
3) Family status
4) DOB of mbr and dependents
5) Plan member identification number
6) Language
7) Date of hire
8) Prov of residence
9) Division, class, billing group
10) Benefits the plan member is covered for
11) Effective date of coverage
12) Coordination of benefits information
6.1.8.a Describe online administration under insured self-administered arrangements
This provides sponsors with access to the insurer’s administration system through data exchange or online access.
Plan member information is transferred from payroll through electronic data transfer or manual entry.
Direct online access allows insurers to complete new enrollments and make changes to member’s data in real time or overnight.
6.1.8.b List 5 tasks that a plan sponsor can use an online administrator to perform
1) Transfer member eligibility information to the insurer
2) Process and update plan member status changes online
3) Calculate plan member contributions for each benefit as well as taxable benefits, premiums and taxes
4) Review premiums, claims and benefit information (read only)
5) Communicate with the insurer
6.1.9 Outline 7 pieces of plan member data the plan sponsor is responsible for inputting on a regular basis
1) New member info
2) Terminations for departing plan members
3) New salary information
4) Changes to benefit levels
5) Changes to plan members’ status (single, family, dependents)
6) Changes to beneficiary designations
7) Requests for medical evidence of insurability
6.1.10 Describe insurer administration
The insurer preforms all or part of the admin functions.
Information of new eligibilities, terminations and other plan member status changes are transmitted electronically. Payroll systems may interface for larger plans, paper for smaller
The sponsor is charged admin costs either as part of premiums, as part or retention expenses or as a separate monthly charge depending on how the plan is funded
6.1.11 Describe 3 services packages offered by TPAs
1) ASO- tracks eligibility, maintains data, handles billing & reporting requirements
2) Claims settlement only. TPA is responsible for all aspects of some claims including certifying eligibility, adjudicating and paying (health, dental, WI/STD)
3) Administration and claims settlement
6.1.12 Describe 4 conditions that may be included in an agreement between and insurer and a TPA
1) TPA maintains complete records on which a claim is based and the claims are the property of the insurer which may review them at any time
2) The TPA processes and in some cases pays claims for specified benefits. Including verifying claims and coverage. May be a dollar limit that requires approval.
3) The TPA is responsible for certain costs arising from omissions and clerical errors made in the event of fraud or negligence
4) The insurer provides an administration manual to the TPA outlining its claims administration procedures along with a supply of claims processing documentation
6.1.13 Outline 6 potential advantages to a plan sponsor outsourcing it’s admin to a TPA
1) More predictable admin costs
2) Access to expertise in a specialized field
3) Increased flexibility and efficiency
4) Ease of administration by having a central contact point
5) Enhanced plan member access, service and satisfaction
6) Customization of services at a competitive cost
6.2.2 Describe the types of forms used to enroll plan members in a group benefits plan
1) Standard - insurers usually require sponsors to use this form
2) Customized incorporates all benefits from various insurers and must be approved by all insurers involved
3) Previous insurer - when a group moves to a new insurer the previous insurer’s forms may be used under certain circumstances. Plan members must be advised and offered the opportunity to update their beneficiaries
