January 2024

Whether you prefer a traditional regional or national provider network or are looking for a more cutting-edge option like a complete network replacement, members deserve the right care, at the right time, in the right setting.

Self-funded health plans offer employers greater flexibility and control over their employee health benefit offerings. With this flexibility comes choice – and when it comes to medical network arrangements, there are various options for employees to access health care services, allowing for a tailored approach to meet the specific needs of an employee-base.  

Whether you prefer a traditional regional or national provider network or are looking for a more cutting-edge option like a complete network replacement, members deserve the right care, at the right time, in the right setting. Let’s explore some of the medical network solutions available to self-funded health plans, each offering unique advantages and considerations.

Traditional Preferred Provider Organization (PPO)

• How it Works: A PPO network consists of a wide range of health care providers, and employees have the flexibility to see any participating doctor or specialist within the network. PPOs come in all shapes and sizes with regional and national network options.

Value-Based or Hybrid Design

• How it Works: This can be a combination of several types of network solutions, such as a Point of Service (POS) plan, where members can access an approved network of providers, or other arrangements where the plan is designed to nudge members to a select higher value providers/facilities or Centers of Excellence (COE). Choosing a COE aligned with employee health care needs – oncology, bariatric, musculoskeletal issues, etc. can be a great way to create an effective network.

Direct Primary Care (DPC)

• How it Works: DPC is a subscription-based model where employees pay a fixed fee for unlimited access to primary care services directly from a designated provider or clinic. DPC can be used as an option along with a traditional network for services outside the DPC or as a full replacement for a traditional network.

Reference-Based Pricing (RBP)

• How it Works: Instead of using a traditional network, RBP sets reimbursement rates for medical services based on a reference point, such as Medicare rates. Employees may face balance billing if they choose providers that charge more than the reference price. Many RBP providers have established strategies to minimize disruption for patients.

Telemedicine Networks

• How it Works: Telemedicine networks provide virtual access to health care professionals, offering consultations through video or phone calls.

Choosing the right medical network arrangement is a critical decision for employers implementing or managing self-funded health plans. The diverse options available cater to different priorities, from flexibility and choice to cost control and preventive care. Health plans are growing in their abilities to share data and conduct their networking to build highly sensitive, directive networks that offer employees the best quality and most cost-effective care. It’s also important to consider your geography, demographics and appetite for change. Understanding the nuances of each arrangement empowers employers to tailor their health benefit offerings to meet the unique needs of their workforce, ultimately fostering a healthier and more satisfied employee population. 

Rather than simply selecting the provider network with the greatest name recognition, employers should work with a trusted benefits consultant or partner to make decisions based on their specific strategy, using market data to define optimal care when possible.  

A third-party administrator (TPA) partner like Nova can highlight these areas, help you navigate the choices, and continually review your network solution to ensure it’s working for the plan population.

Learn more about the advantages for each of these network solutions. [link to Spectrum Red Network 20211 OR Network Solutions White Paper 20215]