Paradigm Health Plans

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The Paradigm Health Plans Solution
sales@paradigmhealthplans.org
www.paradigmhealthplans.org

The Paradigm Position
• Formed in 2007, Paradigm Health Plans® is an industry
leader in self-funded plans, partnering with businesses to
empower employees to actively manage their health care
costs through our Member Advantage Program
• Since 2013, Paradigm has seen an increase in new group
self-funded sales and members of more than 180% over a
two year period
• Paradigm has offices in New Hampshire and Long Island,
New York and is expanding in four US strategic cities first
quarter 2016
• Paradigm’s Member Advantage ProgramSM allows for the
Employer and their Employee’s to reduce or eliminate their
out-of-pocket expenses
• Our Lifestyle-for-Life Program® Health Management
Program includes 38 panel BioMetric Screenings provided on
site

The Paradigm Position
The healthcare market has been evolving and changing for
several years and it will continue to become more complex
Option 1:
Business as Usual
• Brokers continue to be subject to
whatever regulatory changes occur
• Inherit increased costs due to
regulatory changes
• Lack of control and unpredictable
costs for brokers and their clients
Option 2:
Partner with Paradigm
• Brokers and Clients can become
pro-active and regain control of the
quality, access and cost of their
healthcare plan
• Explore Paradigm Health Plan’s
Self-funding Solutions and find out
how our Member Advantage
Program℠ (MAP) saves Clients
and their Employees time and
money!
• Start giving your Clients accurate
Rate Renewal Pricing
OR

The Paradigm Service Model
Reinsurer/Stop Loss
Carriers:
AIG
FSL
Munich RE
Fairmont Specialty
(Crumb and Forrester)
Standard Security
Lifestyle-for-Life
And Health Management
TPA
For Processing
& Billing
Auxiant
Leased Network
CIGNA PPO
AETNA PPO & OA
Anthem BCBS PPO

Plan Designs that Work
• Comprehensive EPO/Health Plans
• 30 FTE and Above
• Wage Parity/Living Wage Plans
• Supplemental for Living Wage
• Minimum Essential Value (MEV)
• Minimum Essential Coverage (MEC)

Workforce/Ancillary Coverage
• Dental
• Vision
• Short and Long Term Disability
• Critical Illness/AD and D/Group Life
• Pharmacy Benefit Management
• Telehealth, Video, Skype Conferencing using 1-800MD

Member Advantage Programs
Find Out How We MAP the Gap
in Healthcare Expectations
• Research and Present the Quality of providers to Members
• Review Benefits Prior to Plan Year Commencement
• Reduce or Eliminate Member OOP Expenses
• Locate in-network providers
• Schedule doctor visits for the family each year
• Provide quality and cost information on providers and procedures such as labs & diagnostics
and surgeries
• Order RX/medications for members- no paperwork!
• Resolve tough billing issues
• Explain the summary of benefits
Each Enrolled Member Is Assigned A Dedicated MAP- that will:

Self-Funded Plan Advantages
• Level Funding: Make 12 payments and you owe nothing else
• True Self-Funded Options
• 100% of unspent claims surplus is returned to Client!
• Access to Tier 1 PPO networks, such as CIGNA, Anthem and Aetna
• Guaranteed Max Rate Cap Increase for 3 renewal cycles (Paradigm Exclusive!)
• Easy Fund: Our New Aggregate Management Program
Determine your maximum annual costs upfront - guaranteed!

Self-Funded Opportunity Grows
The Affordable Care Act
Increases Interest in Self-Funded Plans:
Health Plans once offered to Management and salaried employees only must be
offered to the balance of the workforce scaling up the employers count of employees
As a result, small groups become large groups and become
excellent candidates for self-funded plans
82% of Health Executives
expressed a growing interest in
self-funding their group health
insurance plans
70% of health organizations
were expecting to grow their
self-funding portfolios in 2015

Drivers for Self-Funded Increases
Health Insurance Premiums are Increasing at an unsustainable rate
• Employees pay 89% more for family health care premiums then they did a
decade ago.
• In 2013, premiums rose 4% but that was still twice the rate of wages.
• According to a 2011 Department of Labor report fully-insured premiums
increased by $808 and self-funded premiums increased by $248
Paradigm Health Plans average premium renewal
increase for clients is less that 3.5%

Self-Funded Employers:
Deeper Discounts
using Paradigm Health Plans
• Self-funded plans still meet ACA Guidelines and provide comprehensive benefits
• Employers gain control over their Network selections without limitations in provider
choices (No Narrow Networks or Large Disruption!)
• Paradigm’s Lifestyle-for-Life® Program allows for cost containment with
incorporated biometric screenings, health assessments, disease and care
management and results in a 6-9% savings on claims costs!
• Paradigm’s Member Advantage Program (MAP) embedded in most Paradigm
Health Plans allows for Employers to contain costs when they encourage Members
to utilize the programs
• Members that utilize the MAP Program significantly reduce their out-of-pocket
expenses and can spend money on what they love- not healthcare they need!

Self-Funded vs. Fully Insured
Most Frequently Asked Questions
1. What if claims exceed your monthly payment?
• For Fully-Insured Groups the Insurance Company pays the claims
• For Self-funded Groups, the Stop-Loss carrier pays the claims
2. What if claims are less than your monthly payment?
• For Fully-Insured Groups, the carrier keeps the difference
• For Self-funded Groups, the Employer keeps 100% of the saving!
GUARANTEED!

Controlling Clients and
Members Costs without Disruption

Members will have access to
the Best PPO Networks Available

To contain costs, you must know
where they come from
74% of healthcare costs are due to lifestyle related conditions and
are therefore preventable
52-61% of all claims come from these standardized services:
Rx, Complex Imaging, Urgent Care, Preventative, Labs & Diagnostics
32-37% of all claims are for Inpatient or Surgical procedures at hospitals that
charge more simply because they can
Reduce costs by negotiating all claims above $5k

Paradigm Health Management
Program and True ROI
• 20.7% lower medical spending compared to companies not using the
Lifestyle-For-Life® program
• Reduces medical spend vs. forecast by up to $1,332 per member per year
• 81% of members voluntarily participate in our program and 81% of those Members
achieve measurable improvements in their lifestyle related goals
• 6-9% Annual savings on Claims Cost
Our Lifestyle-for-Life® Program Health Management Program
powered by Interactive Health™

Premier Provider Program
• Premier Providers provide access to the highest quality medical services that
reduce or eliminate the co-pay, co-insurance or deductible costs for the members
• Reduce RX costs by 18% to 22%
• Reduce Complex Imaging costs by 61%
• Reduce Lab & Diagnostics costs by 76%
• Premier Providers remove Facility charges and outpatient hospital excess
claims cost.

Questions?
www.paradigmhealthplans.org
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Paradigm Health Plans

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