UNDERSTAND YOU COVERAGE BEFORE YOU NEED IT

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Call us Today: (303) 242-8766

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Le atendemos en español

UNDERSTAND YOU COVERAGE BEFORE YOU NEED IT

Healthcare highways – what insurance payment?

Healthcare highways - what insurance payment?

In the complex world of healthcare and insurance, one name that has been making waves for mid-sized employers is Healthcare Highways (HCH). Known for its high-performance networks and commitment to delivering quality healthcare while controlling costs, Healthcare Highways is reshaping how employers and employees approach health coverage. Central to this effort is the innovative payment structure and insurance model that Healthcare Highways offers, which is designed to maximize efficiency and cost savings.

In this detailed guide, we will explore what makes Healthcare Highways different from traditional health insurance models, how their payment system works, and the benefits that employers and employees alike can expect when enrolling in Healthcare Highways plans.

Overview of Healthcare Highways

Healthcare Highways (HCH) is not your typical health insurance provider. Their approach revolves around creating high-performance networks of healthcare providers and hospitals, offering tailored plans that focus on cost control and delivering quality care. A key feature of their offering is HCH TrueChoice®, a plan specifically designed for mid-sized employers with 51 to 500 eligible employees.

Healthcare Highways emphasizes financial efficiency by strategically selecting healthcare providers based on quality metrics, ensuring members receive top-notch care while avoiding unnecessary costs. The model benefits both employers and employees by offering a competitive alternative to traditional health insurance networks, which often feature higher premiums and less flexibility.

Key Features of HCH TrueChoice®

Let’s break down some of the main components of HCH TrueChoice® that make it an attractive option for employers:

  • Group Size: This plan is designed for employers with 51–500 eligible employees, making it ideal for mid-sized businesses looking for cost-effective healthcare solutions.
  • Surplus Distribution: One of the key financial advantages of this plan is that employers can receive 50% of the surplus (i.e., the difference between premiums paid and claims made) after a six-month run-out period, provided they renew their contract. This incentivizes businesses to manage their healthcare utilization efficiently.
  • Stop Loss Coverage: Stop loss insurance is a key component in self-funded plans, providing a safeguard against catastrophic claims. Individual stop loss starts at $25,000, with aggregate stop loss options also available, ensuring businesses can cap their liability for high-cost claims.
  • Network Access: Employers and employees gain access to the HCH Sync™ high-performance network, which includes a broad range of healthcare providers who have been selected based on strict quality and performance metrics.
  • Value-Added Services: In addition to basic healthcare services, HCH offers added benefits such as chronic kidney disease management and telehealth options, which improve care outcomes and provide employees with more convenient healthcare access.

How Does Healthcare Highways Insurance Payment Work?

One of the defining characteristics of Healthcare Highways is its unique insurance payment structure, which operates primarily on a self-funded model. Let’s take a closer look at how this payment system functions and why it benefits employers:

Self-Funded Model

In traditional insurance plans, employers pay monthly premiums to an insurance provider, who then covers healthcare claims for employees. In contrast, Healthcare Highways operates under a self-funded or self-insured model, which allows employers to pay directly for healthcare claims as they arise, rather than paying fixed premiums. This offers greater flexibility and can result in significant savings, particularly for businesses with relatively healthy employee populations.

The self-funded model works as follows:

  • Claims Payment: Instead of paying a large monthly premium, employers set aside funds to cover healthcare claims as they are made by employees. This method can reduce overall costs because the employer only pays for actual claims, rather than overpaying for insurance that might not be used.
  • Third-Party Administration: While employers are responsible for paying claims, Healthcare Highways manages the claims processing and provides stop-loss insurance to protect against extremely high-cost claims.
  • Stop Loss Coverage: Employers are safeguarded from large claims through stop-loss insurance, which kicks in when claims exceed a predetermined threshold (e.g., $25,000 per individual). This coverage ensures that the employer’s exposure to catastrophic claims is capped, providing financial protection.

Claims Processing and Payment Structure

The actual claims process for Healthcare Highways members is straightforward. Medical and pharmacy claims are typically processed within five business days, making the reimbursement and payment process efficient. Here’s how it works:

  • Medical and Pharmacy Claims: Employees receive services from providers within the HCH Sync™ network. Claims for these services are sent directly to Healthcare Highways for processing. Members can refer to their ID card for specific claims mailing addresses and instructions.
  • Provider Claims: Providers have access to a Customer Experience Team, which helps with claims questions and processing.
  • Pre-Certification: Certain medical services may require pre-certification, a process where specific treatments or procedures must be approved before being carried out. This ensures that costs are managed and that services are necessary.

Healthcare Highways emphasizes transparency and ease of use when it comes to claims processing, allowing both providers and members to have a streamlined experience.

What Makes Healthcare Highways Different from Traditional Health Insurance?

There are several elements that set Healthcare Highways apart from traditional health insurance models, particularly when it comes to payment structures and cost control mechanisms.

1. Cost Control for Employers

Healthcare Highways focuses on controlling rising healthcare costs through transparent pricing and competition among local healthcare providers. By selectively partnering with providers who meet high-performance criteria, Healthcare Highways can negotiate better rates and ensure that employees receive quality care without unnecessary or inflated costs.

2. High-Performance Networks

The HCH Sync™ high-performance network is a core feature that differentiates Healthcare Highways from other insurance providers. Rather than offering access to a large, often inefficient network of providers, HCH focuses on a curated selection of providers who are chosen based on performance metrics such as patient outcomes, cost efficiency, and service quality. This ensures that employers are only paying for high-value care.

3. Surplus Distribution

In traditional insurance plans, unused premium payments typically go to the insurer. Healthcare Highways, on the other hand, offers a surplus distribution model, where employers receive 50% of any surplus after a six-month period. This surplus is generated when claims fall below the premiums paid, rewarding businesses for efficiently managing their healthcare utilization.

4. Stop Loss Coverage

For employers, the biggest concern with self-funded plans is the potential for catastrophic claims that could put their financial health at risk. Healthcare Highways addresses this concern with stop loss insurance, which limits an employer’s liability by capping the amount they have to pay for high-cost claims. This provides peace of mind and financial security.

Benefits of Healthcare Highways

Healthcare Highways offers a range of benefits for both employers and employees, particularly in the realm of cost control, healthcare quality, and the overall member experience.

1. Cost Control for Employers

By creating competition among local providers and offering transparent pricing, Healthcare Highways helps businesses manage and control their healthcare spending. The self-funded model can lead to significant savings, particularly for employers with lower healthcare utilization.

2. Improved Patient Outcomes

The selective nature of the HCH Sync™ network ensures that employees have access to high-quality providers who are committed to delivering excellent care. This results in better health outcomes for employees, fewer unnecessary procedures, and more effective management of chronic conditions.

3. Enhanced Member Experience

Healthcare Highways also focuses on providing a superior member experience. Employees have access to an online portal, where they can view plan details, claims history, and benefits information. The Customer Experience Team is available to assist with any claims or benefits inquiries, ensuring that members have support when they need it.

Additionally, Healthcare Highways offers access to telehealth services, which provide a convenient option for employees to receive care without having to visit a doctor’s office in person. This service is especially valuable for minor illnesses or consultations that can be handled remotely.

Member Resources

Healthcare Highways provides a range of resources to ensure that members are informed and supported throughout their healthcare journey:

  • Online Portal: Members can log into a dedicated portal to view their claims, check eligibility, and get detailed information about their benefits.
  • Customer Support: The Customer Experience Team is available via phone to help with any questions about claims processing, coverage, or benefits.

These resources empower members to make informed decisions about their healthcare and access services when needed.

Bottom Line

Healthcare Highways represents a shift in the health insurance landscape, offering a model that prioritizes cost control, healthcare quality, and member experience. Their self-funded insurance structure, combined with high-performance networks and surplus distribution, provides significant advantages for mid-sized employers looking to optimize their healthcare spending.

For employers, the flexibility of the self-funded model, coupled with the protection offered by stop loss coverage, ensures that healthcare costs remain manageable. Employees, on the other hand, benefit from access to high-quality care, convenient telehealth services, and a supportive customer experience.

As healthcare costs continue to rise, innovative solutions like Healthcare Highways offer a viable path forward for businesses looking to control expenses while providing excellent care for their employees. By focusing on transparency, efficiency, and performance, Healthcare Highways is setting a new standard in healthcare delivery.

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