Episode Benefit Plans

Many Features Are Similar To PPOs And HMOs

Use of incentives to stay ‘in network’

Programs to enhance a beneficiary’s connection to primary care physicians and virtual care options

Standard administrative programs for enrollment, eligibility, fulfillment, utilization management, provider credentialing, claims administration, pharmacy benefits, general administration, analytics, and reporting

Benefit designs that incorporate deductibles, coinsurance and out-of-pocket maximums

Unique Features Of Episode Benefit Plans

Financial incentives for selecting efficient health care providers for a pending episode of care

These incentives are chosen by employers and can include contributing a portion of the savings (the spending that is less than the episode allowance in the benefit plan) to the employees’ Health Reimbursement Account, direct cash payments to employees, or other forms of rewards that may be offered in cooperation with pharmacies and health providers

For costs exceeding allowances, employers will generally choose increasing beneficiary cost sharing in the form of either increased out of pocket maximums, increased deductibles, or beneficiary liability for a portion of costs in excess of allowances – or some combination of the above based on employer design preference.

Cost sharing for spending above allowances will generally be handled in a manner similar to how Medicare defines the ‘donut hole’, in which a portion of excess costs are, up to a limit, borne by beneficiaries

Our Initial Target Markets