| Feature |
Fully Funded
(Low risk)
|
Shared Funding
(Shared risk)
|
Self-Funded
(high risk)
|
| How do benefits differ? |
- Standardized
- Filed with the State
- Must comply with Michigan and federal legislation (HMO, POS, PPO)
|
- Standardized
- Filed with the State
- Must comply with Michigan and federal legislation (EPO, POS, PPO)
|
- Defined by employer
- Allows more flexibility
- Must comply with federal legislation (EPO, POS, PPO)
|
| How do financials differ? |
- Monthly premiums
- Predictable budget
- Priority Health funds claims
|
- Monthly administrative fees and reinsurance premiums
- Year-end settlement
|
- Monthly administrative fees and reinsurance premiums
- Less predictable for budgeting
- Employer funds claims
|
| What reinsurance options are available? |
Not applicable |
Provided by Priority Health
|
Provided and arranged by Priority Health
|
| What plan documents are required? |
- Group Agreement
- Plan Document Wrap
- Certificate of Coverage
|
- Group Agreement
- Plan Document Wrap
- Certificate of Coverage
|
- Administrative Services Agreement
- Plan Document
- Summary Plan Description
|
| What reporting is available? |
Employer-specific utilization package |
Full disclosure of detailed financial and claims reporting, with regular utilization reporting |
Detailed financial and claims reporting, with regular
utilization reporting |
| Where can you access providers? |
Nationwide
|
Nationwide
|
Nationwide
|
| How is enrollment completed? |
- EDI, Web-based, or paper
- Caller-dedicated enrollment representative
|
- EDI, Web-based, or paper
- Caller-dedicated enrollment representative
|
- EDI, Web-based, or paper
- Caller-dedicated enrollment representative
|
| How are appeals handled? |
Priority Health performs all appeal levels |
Priority Health performs all appeal levels |
- Priority Health performs first-level appeal
- Employer performs second-level appeal, giving employer final
decision-making authority over payment
|
