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Self Funded HMOs - International Foundation of Employee Benefit ...

Self Funded HMOs - International Foundation of Employee Benefit ...

Self Funded HMOs - International Foundation of Employee Benefit

Self-Funded HMOsIN GENERALThe self-funded HMO is similar to a self-funded indemnity plan in that theplan pays: (1) an administrative fee, typically monthly, which is comparable to an ASOfee; (2) fees for services rendered, such as hospital charges, and (3) specialist fees. Thehospital charges paid to the HMO are generally paid in a pass-through manner. Thismeans the employer pays only what the HMO was charged by the hospital, which isusually discounted because of the contractual arrangement between the HMO and thehospital. In deciding whether or not to self-fund, the employer should determine thebasis of billing:• Community-rated• Demographically adjusted.A capitation and self-funded HMO are identical except for the funding.Community-rated. Community rated means all persons in the HMO's service area, thecommunity, are charged the same premium to participate in the HMO. There are nodifferences in the rates charged to an employer to reflect claims experience, utilization,or risk, which vary from employer to employer. Federally- qualified HMOs must becommunity-rated.Demographically adjusted. Demographically adjusted means the demographiccharacteristics of an employer's workforce are used to adjust the rates being charged toan employer. The characteristics most commonly used to adjust rates are age and sex.Federally Qualified HMOsIt might appear that a federally qualified HMO with its community-rated requirementwould not be eligible for the self-funded options. What a federally-qualified HMO mightdo is to clone itself into two entities.• Federally qualifiedThis is funded capitation.• Nonfederally qualifiedThis is self-funded. The federally qualified is a mirror of the nonfederallyqualified. This organizational technique permits the HMO to work both sides of the streetas regards to funding.EMPLOYER APPEALSelf-Funded HMOs 1©2003 International Foundation of Employee Benefit Plans, Inc. All rights reserved.

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