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The Top 6 Best Practices for Employers with Self-Insured Health Plans

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The Top 6 Best Practices for Employers with Self-Insured Health Plans

Below please find the Top 6 Best Practices you and your HR/Benefits Team can implement in 2021 to help maximize the performance and appreciation for your District’s Self-Insured Medical and Prescription Drug program.

#1 Quarterly Vendor Reviews –

Requiring your Third Party Administrator (TPA) and Pharmacy Benefit Manager (PBM) to meet together to review the prior quarter’s claims experience and utilization helps to ensure you and your Team are keeping up to date on trends within the plan’s performance and being made aware of new and improved services available from each of the vendors.  We recommend that each meeting be a year-to-date comparison to the previous year’s data.  It is important that both the TPA and PBM attend these meeting together because their services are so inter-twined and because they need to understand that they each share the same goal – provide your District with the best possible service.  These meetings also provide a great opportunity to discuss and address any service issues that may exist.  Don’t rush these meetings as there is a lot to review – plan 2-3 hours.

#2 Market Each Coverage and Service Every Three Years –

The State of Missouri requires that Public Entities publicly bid their insurance coverages every three years.  We agree that this is very important and would take it a step farther.  Plan to market the District’s fully-insured coverages, self-insured TPA and PBM (stop loss should be marketed every year) as well as your Broker/Consultant/Advisor every three years.  The more effort put into the RFPs, the better the District will be able to identify the best overall value.  For example, RFPs for TPAs and PBMs should include a detailed questionnaire, a request for a managed care network disruption analysis, a medical claim repricing analysis and a formulary disruption and repricing analysis.  In order for the market to provide these analyses, they will need 12 months of detailed claims data included with the RFP.  These analyses provide the best possible means of comparing the strength of the managed care network and discounts and pharmacy contract in terms of both disruption to members and claim savings for the District. 

#3 Pharmacy Benefit Manager Annual Market Check –

While it is prudent if not necessary to publicly bid the District’s PBM services every three years, the District is likely losing tens/hundreds of thousands of dollars in years 2 and 3 if the PBM contract is not renegotiated with the PBM every year.  This is not the same as publicly bidding the PBM services but the PBM has to agree upfront to allow the District the right to negotiate better terms and improve the contract each year.  This has become more and more common throughout the industry. 

#4 Technology – Enrollment, Communications, Education –

Generation Z employees may have different employee benefit needs than Baby Boomers but there is one thing they have in common.  Each group needs to understand what benefits are available to them and how to use them (hopefully wisely).  There are a growing number of options available to Missouri School Districts who understand the importance of leveraging technology for purposes of employee enrollment, communications and education.  Generally speaking, the best approach for communications and education includes a wide variety of media and sources for information as each person has different preferences and learns differently. 

#5 Consumerism and Wellness –

You are probably tired of hearing about these by now.  For 15+ years you’ve been told that the promotion of these two focuses will benefit your District’s plan.  Truth is, these are the ONLY two focuses that will achieve a reduction in long-term plan trend.  These focuses must be used in a strategic approach coupled with short-term (immediate cost-saving and cost shifting strategies like marketing, plan changes, etc.) to achieve the best possible results for your District’s plan.

#6 Be Proactive –

The great news is that there are always improved programs, industry innovations and trends that are developing from which to take advantage.  Onsite/nearsite clinics, concierge and network navigation services, FMLA outsourcing, narrow managed care network options, Centers of Excellence for treatment of specific diseases and illnesses, etc.  The bad news is that it’s a challenge to stay on top of them all.  You need to be able to rely on your Broker/Consultant/Advisor to routinely bring these possible solutions to the table for your District’s consideration.  In fact, your Advisor should be positioned to take the lead on each of these important Best Practices. 


For more information, please contact: Scott S. James
Vice President, Public Entities & Academic Institutions
An MMA Employee Health & Benefits Education Practice Leader