Benefit Plan Administrators - Group Frequently Asked Questions

How do I amend our plan's benefits?
Send a letter requesting a change in benefits to your BPA marketing contact or agent. Benefit Plan Administrators will then determine and notify you of any rate implications. If the changes are acceptable to you, BPA will prepare an amendment to your plan.

What is a TPA?
A Third Party Administrator is a non-risk bearing company that specializes in administering an agreed upon plan for a self-funded group. The TPA is responsible for processing and paying eligible claims, billing and generating any special reports for the employer. A TPA is not an insurance company.

What is self-funding?
Self-funding is based on the concept that health insurance is designed to protect against two different areas of exposure: predictable costs and unpredictable costs.

Predictable costs are most efficiently funded and paid by the employer. Purchasing insurance to cover predictable claims is not cost effective due to the loads for overhead, taxes, profit, sales commission, and reserves. Those overhead costs are in addition to the full amount of the predictable claims. Self-funding these predictable claims results in a direct savings of medical insurance premium loads.
Unpredictable costs, such as shock claims or catastrophic losses, are justifiably insured through an excess-loss contract with an insurance carrier. Premiums are much lower for this type of coverage, so the insurance company loads are correspondingly lower.

Why self-fund?

Answers:
a. Increase Cash Flow

A Self-funded plan does not require pre-funding of future claims or reserves for "incurred but not paid" claims. This allows the employer full usage of working capital and interest earnings on any money in the insurance fund.

Fixed costs of a self-funded plan are normally less than those of a conventional fully-insured plan. Savings result from lower claim administrative costs, premium taxes, commissions, and overhead costs that are far below those of fully-insured products.

b. Employer Control

The employer can develop a plan of benefits tailored to the needs of its employees.

The employer has complete control and knowledge of where and how contributions are distributed.

c. Share the Risk

Excess-loss insurance can protect the employer in a "bad" claims year. In a "good" claims year, the savings in paid claims are available immediately since the funds remain in the employer's control.

What is a self-insured group?
A self-insured group health plan (or a 'self-funded' plan as it is also called) is one in which the employer assumes the financial risk for providing health care benefits to its employees. In practical terms, self-insured employers pay for employee medical costs as they are incurred instead of paying a fixed premium to an insurance carrier for what is known as a fully insured coverage. Typically, a self-insured employer will set up a special trust fund to earmark money (corporate and employee contributions) to pay claims as they are incurred.

Self-insured employers can either administer the payment of claims in-house, or subcontract this service to a third party administrator like BPA. Third party administrators can also help employers set up their self-insured group health plans and coordinate stop-loss insurance coverage, provider network contracts and utilization review services.

What other services/benefits does BPA offer?
Benefit Plan Administrators also administers Flex Benefits, Short Term Disability, and Dental plans. Furthermore, BPA provides fully insured options for Health, Dental, Short Term Disability, and Voluntary products.

CLAIMS

An employee has come in with a bill that they received from their doctor. Why has this bill not been paid?
There are several reasons why the bill has not been paid.

Has it been received in our office yet?

Does the doctor have the correct insurance information?

Is the claim submission address correct? To resolve this issue, it would be best to contact our toll-free number 800-236-7789 and speak with a Customer Service Representative.

A claim has been processed for payment, but nothing was paid. Why not?
There are several reasons why the bill has not been paid.

Does the plan have a deductible?

Does the plan have separate in and out of network benefits?

Is the provider in the network? To resolve this issue, it would be best to contact our toll-free number 800-236-7789 and speak with a Customer Service Representative.

COBRA

What is COBRA?
COBRA (Consolidated Omnibus Budget Reconciliation Act) is a temporary extension of your Medical and/or Dental Insurance if you have been terminated from the plan or have been terminated from your employment for any reason other than gross misconduct. For more information, you can link to the U.S. Department of Labor's website www.dol.gov/ebsa/faqs/faq_consumer_cobra.html

An employee has terminated. Do I send a COBRA notification or a change form?
A COBRA Notification is necessary when an employee terminates because the plan is obligated to notify the insured of their rights. If BPA administers your COBRA or if the employee is still working for your company but has decided to terminate his/her coverage, then a change form is sufficient.

How long do I have to notify BPA of an employee's termination?
A change form has to be received at BPA within 30 days of the termination date.

If an employee terminates in the middle of the month, when is their insurance termination date?
The employee's insurance termination date will depend on the definition in your Summary Plan Description, Eligibility section.

How long is the insured eligible?
Eligibility for COBRA is dependent upon the qualifying event. Termination from employment entitles you to 18 months of coverage. Disabled continuers may be eligible for an extension beyond 18 months. Death of the covered employee, divorce or legal separation from the covered employee, a dependent child ceasing to be covered as defined in the terms of the plan, or a covered employee becoming entitled to Medicare benefits entitles the insured to 36 months of coverage. For more information, you can link to the U.S. Department of Labor's website www.dol.gov/ebsa/faqs/faq_consumer_cobra.html

How does the insured make their COBRA premium payments?
Upon receipt of the original signed and dated COBRA Election Form, a confirmation letter will be sent to the former insured. The first is due, paid to the order of Benefit Plan Administrators, 45 days after the confirmation letter is sent. Every seceding payment is due on the first day of the month for the upcoming month. Payment is made to BPA if we administer your COBRA benefits. Otherwise payments are made directly to the employer.

How does my company know if an insured is paying for COBRA?
If BPA administers your COBRA, at the bottom of each month's Premium Billing Statement, each COBRA participant who has made a payment for since the previous month will be listed. The name of the participant and the month of coverage for which the participant paid, as well as the premium for which the company is responsible, will be listed at the bottom of the bill.

HIPAA

What is HIPAA?
HIPAA (Health Insurance Portability and Accountability Act) states that no one can be denied coverage based upon a pre-existing condition and that no one will be required to present evidence of insurability before joining a new insurance plan. HIPAA provides that a pre-existing condition exclusion, up to but not exceeding 18 months, may be imposed on all late enrollees. The pre-existing condition exclusion can be reduced or eliminated with the presentation of a Certificate of Creditable Coverage, which lists previous creditable coverage held by the insured. Further information regarding the laws and regulations of this law can be found by linking to the U.S. Department of Labor's website www.dol.gov/ebsa/publications/top15tips.html

How do I obtain a Certificate of Creditable Coverage?
A BPA Certificate of Creditable Coverage (CCC) can be obtained by contacting Customer Service at our toll-free number 800-236-7789 or by sending us an e-mail at services@bpaco.com. If you need a CCC from another insurer, please call them directly.

PRESCRIPTION DRUG CARD

An employee says that their card did not work for a medication that I thought was covered. What should I do?
Obtain a copy of the card that the employee used at the pharmacy, the name of the medication that they were trying to obtain, what the pharmacist said, and call Customer Service at 800-236-7789 or email us at services@bpaco.com.

How do I order an extra Prescription Drug Card for an employee?
To obtain a new card, either call Customer Service at 800-236-7789 or email us at services@bpaco.com.

PREFERRED PROVIDER ORGANIZATION

What is a PPO?
A PPO (Preferred Provider Organization) is a "network" of providers (doctors, hospitals, specialists, etc.) that you may access to obtain "in-network" level benefits. However, as part of a PPO, you may see any provider, even if the provider is not part of the "network".

Explain/Clarify the relationship between a PPO and BPA.
A PPO (Preferred Provider Organization is a "network" of providers (doctors, hospitals, specialists, etc.) that you may access to obtain "in-network" level benefits. Benefit Plan Administrators contracts with the PPO to offer the services of participating PPO practitioners to our members. In other words, BPA administers the plan (i.e. processes the claims, answers benefit questions, produces billing and identification cards) while the PPO makes available the network of providers.

Benefit Plan Administrators has several contracts with PPOs around the country, including WPPN, Multiplan, Touchpoint, PlanVista, Preferred One, Advance PCS, and more! All of these PPOs make available providers that members can visit while BPA processes the claims from the visits.

In order to find a provider in a particular network, you may either access the PPO's website from our partners webpage or contact them directly.

BILLING

Why does my check register not match my deposit request?
The deposit request is based upon the company's unpaid claims processed by Benefit Plan Administrators at the time that the report was generated. Any adjustments (i.e. claims pended, released from pending, voided or a refund received) made after you receive the deposit request and before BPA receives your funding, may affect the value of the next scheduled check run. This discrepancy will usually leave a small balance remaining in your account, which will automatically be deducted from the next deposit request.